School dental programs
School dental programs include screening students for dental needs, sealant programs to protect students’ permanent molars, fluoride treatment, and other preventive dental care. Services can be provided by dental professionals, often those employed by Federally Qualified Health Centers (FHQCs), via mobile vans parked at schools, or stationary or portable equipment within schools; services may be provided only in schools or students may be linked to clinics for additional care. Programs often serve school districts with high proportions of children from families with low incomes and school districts in rural areas1.
What could this strategy improve?
Expected Benefits
Our evidence rating is based on the likelihood of achieving these outcomes:
Reduced cavities
Increased access to oral health care
What does the research say about effectiveness?
There is strong evidence that school dental programs increase access to oral health care1, 2 and prevent cavities, especially for children from families with low incomes1, 2, 3, 4, 5, 6, 7, 8.
Sealant programs substantially reduce cavity formation in sound, pitted, and fissured teeth1, 9, especially for children from families with low incomes1, 10. Effects are strongest when programs seal the newly erupted molars of second and sixth graders5, treat children with the highest risk of cavity development, and perform services directly in schools rather than at local clinics1. Sealants appear to stay on teeth longer when programs use two-person teams to apply them5, though additional personnel costs may reduce the number of students a program can serve11. School dental programs that employ registered nurses to apply fluoride varnishes have been shown to reduce cavities in treated children to the same degree as programs with dental hygienists3. An Oregon-based evaluation of a dental pilot program for children from families with low incomes suggests that preventive dental care provided by dental hygienists at school dental clinics may improve children’s oral health, may reduce cavities, and may increase parents’ satisfaction with their children’s dental care12.
Fluoride supplements13, toothpastes, mouth rinses, gels, or varnishes also prevent cavities, although students may be most likely to use toothpaste14. Fluoride varnishes and dental sealants prevent cavities when applied to permanent molars15. Fluoride treatments may increase the risk of fluorosis for children under age six16, 17; additional research is needed regarding potential adverse effects of swallowing fluoride gels14, 18.
School-based dental programs may reduce costs by performing screenings and applying sealants during the same visit1, and programs serving larger schools can reduce costs by employing an extra assistant and chair so that dentists and hygienists can move from one sterilized station to the next. Reducing supervision requirements for dental hygienists can also reduce the cost of sealant programs in many states11; school dental programs that employ dental hygienists to assess oral health and apply sealants cost less than programs with dentists in these roles1, 19.
The Centers for Disease Control and Prevention (CDC) considers preventively sealing the molars of all children from families with low incomes a cost-effective strategy5; sealant programs are most cost-effective when focused on children at high risk of developing cavities (i.e., children from families with low incomes, past history of cavities, high sugar diet, enamel defects, etc.)9. Overall, school-based sealant programs appear to become cost saving within two1 to four years10. In Connecticut, Federally Qualified Health Centers (FQHCs) appear to have saved 50% per dental patient by treating children in their schools rather than in clinics20. Additional research on barriers to establishing and maintaining sealant programs at schools is needed to improve the long-term sustainability of programs21.
A national study of school dental programs suggests that partnerships between schools and medical and dental providers can increase students’ participation and that mobile dental units can improve access for students whose working parents are unable to take their children to dental offices21. Services delivered via school partnerships with mobile dental clinics appear to reduce cavities among children living in under-resourced, rural areas22.
How could this strategy advance health equity? This strategy is rated potential to decrease disparities: supported by strong evidence.
There is strong evidence that school dental programs have the potential to decrease disparities in access to oral health care when implemented in communities with lower incomes and higher rates of cavities among children1, 2. For participating students, programs have been shown to reduce cavities, increase the number of dental treatments received, and decrease disparities in tooth decay1.
A New York City-based study of school dental clinics in schools primarily treating students from families with low incomes or identifying as Black or Hispanic, found that applying silver diamine fluoride reduces cavities to the same degree as dental sealants and atraumatic restorative treatment2. A study of school dental programs located across 16 states suggests that use of dental sealants increases when programs are implemented in high-needs schools (i.e., more than half of students participate in free or reduced-price meal programs)21.
Partnerships between school dental programs and varied types of providers can support access to oral health care for previously underserved children. Partnerships between school dental programs and dental schools appear to increase access to oral health care for children from families with low incomes and support the training of future dentists29. Services delivered via school partnerships with mobile dental clinics appear to reduce cavities among children living in under-resourced, rural areas22. Children residing in rural areas often experience poorer oral health and more cavities than children in urban or suburban areas due to lack of access; school dental programs in rural areas have the potential to reduce this disparity by increasing access to providers30.
Children and adolescents from families with low incomes are more likely to experience cavities than wealthier peers, which can cause pain, difficulty eating, and infections, and contribute to lower school attendance and lower grades21. While rates of untreated tooth decay have improved over the past 20 years (10% compared to 20%), as of 2023, by the age of 19, 65% of children from families with low incomes have had a cavity, with higher rates for children of Mexican American or American Indian and Alaska Native heritage31.
What is the relevant historical background?
Health care options within schools began in the early 1900s with the addition of nurses to treat children’s minor injuries or illnesses emerging during the school day32, 33, and by 1911, there were 102 cities with nurses in their schools33. Prior to World War I, roughly 70 U.S. cities sponsored school dental clinics, staffed by dentists, offering reparative and restorative care; participating dentists viewed this as a public service commitment and as a way to prevent disease34. Free services continued throughout the Great Depression and the number of programs grew even as children’s treatment at private dental clinics declined34.
However, by the late 1950s, roughly half of school-aged children were being treated approximately once a year by dentists in private practices; school dental programs began to be regarded by dental providers as offering lesser care and more suited to oral health education than oral health treatment34. Other oral health improvement efforts, including community water fluoridation, the promotion and acceptance of daily toothbrushing, fluoride toothpaste, and advances in dental treatment and preventive care significantly reduced cavities among children during the second half of the 20th century31. Yet, the use of preventive dental care by children from families with low incomes decreased by roughly 10% from 2016 to 202135.
In recent years, some states have established school dental screening laws or school-linked programs as a way to direct children to dental care. Yet, referral tracking systems must be in place to ensure children receive the recommended care. California’s school-based electronic referral management system shows promise31.
As of 2024, more than 74 million people in the U.S. reside in one of approximately 7,400 federally designated dental health professional shortage areas (HPSAs)36; most areas are rural or remote37.
Equity Considerations
- How can students and families be involved in decisions surrounding the availability of school dental programs?
- How can school dental programs and partners foster trusting relationships between providers and underserved students and families? How can partnerships expand to benefit the students and families via outreach efforts in the broader community?
- Can school dental programs offer care beyond the school day to promote parent and guardian involvement in their children’s dental care?
- What additional funding streams (e.g., local, state, or federal government; non-profits, private organizations) can school dental program administrators pursue to make programs sustainable and expand services to treat additional students in need? How can program partnerships with dental service providers (e.g., dental schools, dental hygiene or therapy education programs) reduce the cost of care and expand the number of available providers?
Implementation Examples
School dental programs may be supported by a variety of private and public entities. Boston University, for example, runs school-based oral health programs at 20 schools and 30 preschools in Boston, providing dental screenings, fluoride and sealant applications, and oral health education, along with programs in an additional eight cities in Massachusetts23. St. David’s Foundation in Central Texas provides dental care at Title 1 elementary schools via one of the largest mobile dental fleets in the country24. Multnomah County, Oregon and DuPage County, Illinois have programs tailored to serve children from families with low incomes25, 26.
The University of Florida College of Dentistry sponsors three types of school dental programs: the Oral Health Surveillance Program provides annual dental screenings for third grade students across Alachua County’s 21 elementary schools and Collier County’s 36 elementary schools; the Alachua County School-Based Dental Sealant Program offers dental sealants to elementary and middle school students, in partnership with the United Way of North Central Florida; and the Head Start Fluoride Varnish Program provides fluoride varnish to attending preschool aged children from families with low incomes27.
Seal America’s School-Based Dental Sealant Program Training guides school administrators and dental professionals throughout the planning, implementation, and sustainability phases of a school dental sealant program28.
Implementation Resources
‡ Resources with a focus on equity.
CDC-School sealant - Centers for Disease Control and Prevention (CDC). (n.d.). School sealant programs. Retrieved December 9, 2024.
CDPH-Children’s dental disease - California Department of Public Health (CDPH). (2022). Children's Dental Disease Prevention Program: School-based and school-linked programs. Office of Oral Health. Retrieved December 15, 2024.
Seal America - Seal America: The Prevention Invention. (2023). School-Based Dental Sealant Program Training. National Maternal and Child Health Oral Health Resource Center. Retrieved December 15, 2024.
Big Smiles Dental - Big Smiles Dental. Dental care right outside your classrooms.
Footnotes
* Journal subscription may be required for access.
1 CG-Oral health - The Guide to Community Preventive Services (The Community Guide). Oral health.
2 Ruff 2024a - Ruff, R. R., Godin, T. B., & Niederman, R. (2024). Noninferiority of silver diamine fluoride vs sealants for reducing dental caries prevalence and incidence: A randomized clinical trial. JAMA Pediatrics, 178(4), 354-361.
3 Ruff 2024 - Ruff, R. R., Godín, T. B., & Niederman, R. (2024). The effectiveness of medical nurses in treating children with silver diamine fluoride in a school-based caries prevention program. Community Dentistry and Oral Epidemiology, 52(4), 398-405.
4 Starr 2021 - Starr, J. R., Ruff, R. R., Palmisano, J., Goodson, J. M., Bukhari, O. M., & Niederman, R. (2021). Longitudinal caries prevalence in a comprehensive, multicomponent, school-based prevention program. The Journal of the American Dental Association, 152(3), 224-233.e11.
5 CDC-Gooch 2009 - Gooch BF, Griffin SO, Gray SK, et al. Preventing dental caries through school-based sealant programs: Updated recommendations and reviews of evidence. Journal of the American Dental Association. 2009;140(11):1356–65.
6 Simmer-Beck 2015 - Simmer-Beck M, Walker M, Gadbury-Amyot C, et al. Effectiveness of an alternative dental workforce model on the oral health of low-income children in a school-based setting. American Journal of Public Health. 2015;105(9):1763-1769.
7 Carpino 2017 - Carpino, R., Walker, M. P., Liu, Y., & Simmer-Beck, M. (2017). Assessing the effectiveness of a school-based dental clinic on the oral health of children who lack access to dental care: A program evaluation. The Journal of School Nursing, 33(3), 181-188.
8 Niederman 2008 - Niederman R, Gould E, Soncini J, et al. A model for extending the reach of the traditional dental practice: The ForsythKids program. The Journal of the American Dental Association. 2008;139(8):1040-1050.
9 Tinanoff 2015 - Tinanoff, N., Coll, J. A., Dhar, V., Maas, W. R., Chhibber, S., & Zokaei, L. (2015). Evidence-based update of pediatric dental restorative procedures: Preventive strategies. The Journal of Clinical Pediatric Dentistry, 39(3), 193–197
10 CG-Griffin 2017 - Griffin, S. O., Naavaal, S., Scherrer, C., Patel, M., Chattopadhyay, S., & Community Preventive Services Task Force (2017). Evaluation of school-based dental sealant programs: An updated Community Guide systematic economic review. American Journal of Preventive Medicine, 52(3), 407–415.
11 Scherrer 2007 - Scherrer CR, Griffin PM, Swann JL. Public health sealant delivery programs: Optimal delivery and the cost of practice acts. Medical Decision Making. 2007;27(6):762–71.
12 Kohli 2022 - Kohli, R., Clemens, J., Mann, L., Newton, M., Glassman, P., & Schwarz, E. (2022). Training dental hygienists to place interim therapeutic restorations in a school-based teledentistry program: Oregon’s virtual dental home. Journal of Public Health Dentistry, 82(2), 229–238.
13 Cochrane-Tubert 2011 - Tubert-Jeannin S, Auclair C, Amsallem E, et al. Fluoride supplements (tablets, drops, lozenges or chewing gums) for preventing dental caries in children. Cochrane Database of Systematic Reviews. 2011;(12):CD007592.
14 Cochrane-Marinho 2015 - Marinho VCC, Worthington HV, Walsh T, Chong LY. Fluoride gels for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews. 2015;(6):CD002280.
15 Cochrane-Kashbour 2020 - Kashbour, W., Gupta, P., Worthington, H. V., & Boyers, D. (2020). Pit and fissure sealants versus fluoride varnishes for preventing dental decay in the permanent teeth of children and adolescents. Cochrane Database of Systematic Reviews, (11), CD003067.
16 Pizzo 2007 - Pizzo G, Piscopo MR, Pizzo I, Giuliana G. Community water fluoridation and caries prevention: A critical review. Clinical Oral Investigations. 2007;11(3):189-193.
17 Prystupa 2011 - Prystupa J. Fluorine - A current literature review. An NRC and ATSDR based review of safety standards for exposure to fluorine and fluorides. Toxicology Mechanisms and Methods. 2011;21(2):103–70.
18 Ammari 2007 - Ammari, J. B., Baqain, Z. H., & Ashley, P. F. (2007). Effects of programs for prevention of early childhood caries: A systematic review. Medical Principles and Practice, 16(6), 437–442.
19 Neidell 2016 - Neidell M, Shearer B, Lamster IB. Cost-effectiveness analysis of dental sealants versus fluoride varnish in a school-based setting. Caries Research. 2016;50(Suppl 1):78–82.
20 Bailit 2012a - Bailit HL, Beazoglou TJ, DeVitto J, McGowan T, Myne-Joslin V. Impact of dental therapists on productivity and finances: III. FQHC-Run, school-based dental care programs in Connecticut. Journal of Dental Education. 2012;76(8):1077-81.
21 Patel 2022a - Patel, N., Griffin, S. O., Linabarger, M., & Lesaja, S. (2022). Impact of school sealant programs on oral health among youth and identification of potential barriers to implementation. The Journal of the American Dental Association, 153(10), 970-978.e4.
22 Enciso 2015 - Enciso R, Sundaresan S, Yekikian M, Mulligan R. Oral health status of children attending a mobile dental clinic—A comparative study. Journal of Health Care for the Poor and Underserved. 2015;26(4):1418–1427.
23 Boston School-based dental - Boston University, Henry M. Goldman School of Dental Medicine. School-based oral health programs: 5 city wide prevention programs operating in 61 Boston schools.
24 St. David’s Dental Program - St. David’s Foundation. (n.d.). Mobile Dental Program: Providing preventative and restorative care to elementary school students since 1998. Retrieved December 15, 2024.
25 Multnomah-School oral health - Multnomah County, OR. School and community oral health: A field-based program that promotes oral health, disease prevention, and access to dental care for children.
26 DuPage County-Dental health - DuPage County Health Department, Illinois. Dental Health Program.
27 UF School-based programs - University of Florida, College of Dentistry. (n.d.). School-based programs. Retrieved December 15, 2024.
28 Seal America - Seal America: The Prevention Invention. (2023). School-Based Dental Sealant Program Training. National Maternal and Child Health Oral Health Resource Center. Retrieved December 15, 2024.
29 Partido 2021 - Partido, B. B., Bean, C., Chartier, E. A., & Sprinkle, E. (2021). Outcome evaluation of the dental health outreach mobile experience (HOME) coach program. Journal of Dental Education, 85(1), 37-43.
30 Dawkins 2013 - Dawkins E, Michimi A, Ellis-Griffith G, et al. Dental caries among children visiting a mobile dental clinic in South Central Kentucky: A pooled cross-sectional study. BMC Oral Health. 2013;13(19).
31 Kumar 2023 - Kumar, J., Crall, J. J., & Holt, K. (2023). Oral health of women and children: Progress, challenges, and priorities. Maternal and Child Health Journal, 27(11), 1930–1942.
32 Ryst 2021 - Ryst E, Joshi S V. Collaboration with schools and school-based health centers. Child and Adolescent Psychiatric Clinics of North America. 2021;30(4):751-765.
33 North 2020 - North S, Dooley DG. School-based health care. Primary Care: Clinics in Office Practice. 2020;47(2):231-240.
34 RAND-Schlossman 1986 - Schlossman, S. L., Brown, J., & Sedlak, M. (1986). The public school in American dentistry. RAND Corporation.
35 CDC-Oral health disparities - Centers for Disease Control and Prevention (CDC). (2024, May 15). Oral health: Health disparities in oral health. Retrieved December 9, 2024.
36 Khan 2024 - Khan, M., Catalanotto, F., Singhal, A., & Revere, F. L. (2024). Integration of dental therapists in safety net practice increases access to oral health care in Minnesota. Journal of Public Health Dentistry, 84(3), 281–288.
37 Akinlotan 2023 - Akinlotan, M. A., Ferdinand, A. O., Maxey, H. L., Bolin, J. N., & Morrisey, M. A. (2023). Dental hygienists’ scope of practice regulations and preventable non-traumatic dental emergency department visits: A cross-sectional study of 10 U.S. states. Community Dentistry and Oral Epidemiology, 51(2), 274–282.
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