COMMUNITY INTERVENTION FOR DENTAL CARIES
Community Intervention for Dental Caries
Avril James-Hurt
MPH 607: Community Health Analysis
Benedictine University
Professor Uche S. Onwuta
Background
Rural Healthcare Disparities
The Agency for Healthcare Research and Quality (AHRQ) (2010) defines rural as a twofold concept: “micropolitan statistical area” of 10,000 to 50,000 inhabitants and “noncore statistical area”, which is smaller than a micropolitan area. Despite 25 percent of Americans live in rural communities, they have unique healthcare concerns; “Compared with urban Americans, rural residents have higher poverty rates… tend to be in poorer health, have fewer doctors, hospitals, and other health resources, and face more difficulty getting to health services” (AHRQ, 2010, p. H-10). The AHRQ (2010) explains further, “Residents of micropolitan areas had worse access to care for 50% of access measures. Residents of noncore areas had worse access to care for about 40% of access measures” (p. H-11).
Rural children suffer health the aforementioned disparities; more than 30 percent of young children in the rural southern United States are poor. Due to their developing bodies; younger children are especially vulnerable to negative health outcomes. Childhood health problems can persist into adulthood. McKenzie, Pinger, & Kotecki (2008) explain it is difficult for unhealthy children to learn. Early childhood poverty is correlated with fewer years of completed matriculation, which perpetuates the cycle of poverty (Mattingly & Stransky, 2010).
Community Description
Donalsonville, GA is a rural community in Seminole County. According to the US Census Bureau (2009), there were 2,669 people and 2,589 households within the city. The population density was 702.8 people per square mile (271.2/km²) (Donalsonville, Georgia, 2011).
The racial characteristics of the city are: White: 864 (32.4%); Black or African American: 1,705 (63.9%) ; Asian: 69 (2.6%); Two or more races 31 (1.2%); Hispanic or Latino (of any race) 31 (1.2%).
The median household income was $23,869, and the median family income was $24,127. The per capita income for the city was $14,099. Approximately, 30% of families and 30% of the population were below the poverty line (US Census Bureau, 2009).
Determining a Health Problem
A kindergarten teacher, at Seminole County Elementary School, who was the daughter of an Atlanta dentist, noticed a high percentage of children with discolored teeth in her kindergarten class. She feared a high degree of dental caries and wanted to instigate an intervention. However, when she presented this idea to the school several other health problems were identified. The president of the PTA wanted to address obesity prevalence in the school. Additionally, the school nurse wanted to address the incidences of colds and flu. The principle contacted the Georgia State Office of Rural Health (SORH); an epidemiologist was sent to assist the school by prioritizing the health concerns and implementing an intervention.
Hanlon Method of Prioritization
“Rate against specified criteria – Once a list of health problems has been identified, on a scale from zero through ten; rate each health problem on the following criteria: size of health problem, magnitude of health problem, and effectiveness of potential interventions. It is important to remember that this step requires the collection of baseline data from the community such as from a community health assessment” (NACCHO, 2010).
Rate the Size of the Problem
Dental Caries
With informed consent, volunteer dental hygienists performed examinations on the children: determined 60% dental caries; ranked 10 using Hanlon Method.
Obesity
With informed consent, the school nurse obtained body weight and height information on all kindergarteners: determined 15% obesity rate; ranked 8 using Hanlon Method.
Colds/Flu
The epidemiologist reviewed sick day excuses for the 200 kindergarteners; 100 had been absent during the previous year: 25% unexcused, 25% cold/sore throat, 10% toothache, 10% joint injuries, 10% mental health, 10% overslept, and 10% miscellaneous; ranked 7 using Hanlon Method.
Rate the Seriousness of the Health Problem
Each question is ranked 1-3 to indicate severity; the total score of the questions ranks seriousness.
What is the emergent nature of the problem? Is there public concern?
Dental caries
Dental caries initiated the campaign, additionally; it was previously unknown how many children were affected. “Dental caries is the most common chronic disease suffered by children; five times more prevalent than asthma and seven times more prevalent than hay fever. More than 50 percent of all children experience dental caries by the age of eight years. About 80 percent of all children have dental caries by age 18.4 In addition to its prevalent nature, dental caries is typically irreversible” (Fos & Hutchinson, 2003). Dental caries is ranked 3.
Obesity
Obesity rate is seen as high; however, a campaign had been introduced two years before. Obesity is ranked 2.
Colds/Flu
The school had not experiences an increase in colds or flu. H1N1 did not affect the school district. Additionally, colds were seen as a part of childhood. Colds/Flu is ranked 2.
What is the severity? Does it cause hospitalization or premature death?
Dental Caries
Dental caries may not cause immediate death; however, dental disease in correlated with heart disease (Fos & Hutchinson, 2003). Additionally, dental caries is associated with bacterial infection. Dental caries is ranked 2.
Obesity
Obesity is also correlated with several comorbidities; however, they are generally chronic conditions. Obesity is ranked 2. Cold/Flu
While most people recover from the common cold without complications, the flu can directly cause death. Cold/Flu is ranked 3.
What is the economic loss associated with problem? Is there long term care?
Dental caries
“Poor oral health can have a significant impact on children’s overall health, growth and development, and learning. In fact, children’s dental-related illnesses are responsible for more than 51 million lost school hours each year” (AHRQ, 2003, para. 1). Dental caries is ranked 3.
Obesity
Obesity “When compared to adolescents with BMI in the 95th–96.9th percentile, youth with a BMI ≥99th percentile had significantly different mean levels of systolic and diastolic blood pressure, HDL cholesterol, and insulin” (Skelton, Cook, Auinger, Klein, & Barlow, 2009, “abstract”) . These children are at increased risk for chronic disease which needs long-term management. Obesity is ranked 3.
Colds/Flu
In 2003, “The greatest economic impact of the common cold is in lost work-related time. American children lost around 189 million school days. Parents stayed home to take care of their sick children and lost over 126 million workdays. Combining the cost of parents staying home with employees staying home because of the common cold led to work-related losses for the economy of more than $20 billion (Jones, 2003). However, for this school, colds/flu experienced few sick days. Cold/Flu is ranked 2.
Total score:
Dental Caries: 8
Obesity: 7
Colds/Flu: 7
Rate the effectiveness of available interventions
Dental caries
One study found that permanent molar surfaces with dental sealants were 50 percent less likely to have dental decay. “This study also determined that dental sealant usage is most beneficial in those children and adolescents who are at risk for occlusal caries” (Fos & Hutchinson, 2003, para. 3).
An additional intervention is the use of mobile dental clinics, “by removing cost, time, transportation, and bureaucratic barriers, the program was able to reach more children than fixed-site clinics” (Jackson, et al., 2007). Based on a 50% reduction in incidence, this intervention is ranked 6.
Obesity
“Sixteen studies examined the effects of school-based interventions on obese children, and all studies but one found that treatment reduced at least some measure of obesity” (Skelton, Cook, Auinger, Klein, & Barlow, p. 1, 2009).
However, another peer-reviewed study indicates, community-based interventions designed to prevent obesity in children appear to be more effective with those under the age of five; in adolescents, mixed results occurred (International Association for the Study of Obesity, 2010). Additionally, this intervention requires rigorous coordination with the family to promote good behavior away from school; this intervention is ranked 6.
Cold/Flu
Hand washing campaign reduces absenteeism from 3.02 days to 2.42 days (CDC, 2004). Flu shots are the best prevention against the flu virus; however, they are costly and some parents may object. The intervention is ranked 4.
PEARL Test
Propriety, Economics, Acceptability, Resources, Legality
Dental caries
“Yes” to all measures.
Obesity
“No” due to acceptability and resources; parental participation may be inadequate.
Cold/Flu
“No” due to acceptability and legality of flu shots.
Table 1
Health Problem Priority Setting Worksheet
Health Problem
A:
Size
B:
Seriousness
C:
Effectiveness of Intervention
D:
Priority Score
(A + 2B) C
E:
Rank
Dental Caries
10
8
6
(10 + 16) 6 = 156
1
Obesity
8
7
6
(8 + 14) 6 = 132
2
Colds/Flu
7
7
4
(7 + 7) 4 = 56
3

Risk Factors and Indirect Factors
Risk Factors
After completion of the Hanlon method of prioritization, it was determined that dental caries would be addressed with an intervention. Risk factors for dental caries include: bacteria present in plaque that adheres to the teeth. Plaque that is not removed from the teeth mineralizes, ultimately, resulting in gum disease (“Dental Cavities - Dental Cavity Causes, Symptoms, Treatments”, 2011).
Additionally, sugar creates an acidic environment which degrades tooth enamel. “Sticky foods are more harmful than non-sticky foods because they remain on the surface of the teeth. Frequent snacking increases the time that acids are in contact with the surface of the tooth” (“Dental Cavities - Dental Cavity Causes, Symptoms, Treatments”, 2011).
Indirect Factors
Several direct and indirect factors (which are the level of intervention) exist which contribute to poor oral hygiene and increased sugar consumption. Poor oral hygiene is a direct contributing factor to increased bacterial growth. A low-quality diet has increased sugar. As mentioned, a lower socioeconomic status is correlated with less education. Undereducated parents may not understand the need to develop good oral hygiene and may not understand the negative implications of a high-sugar diet. The National Rural Health Association (2005) lists eight indirect factors: geographic isolation, lack of adequate transportation, lack of fluoridated water, higher rates of poverty, large percentage of elderly, lower dental insurance rates, acute provider shortages, and difficulty finding providers who will accept Medicaid.

Intervention
Based on the aforementioned indirect factors; a community-level intervention will include the use of a mobile dental clinic. One county dentist has volunteered to dedicate time, bi-annually to conduct the examinations. In addition, the epidemiologist was able to procure the help of three hygienists. Under the management of ReachOut Healthcare America (2011), this structure works with providers to deliver:
“Clinical care (exams, x-rays, cleaning, fluoride, sealants, fillings), case management (communication with parent or guardian; ensuring treatment plan, referrals), outreach in a culturally sensitive manner (bilingual consent forms, phone-based outreach), and ease of use (only a room needed and no human resources support from the site)” (para.1).
The program was incepted in 1997 and brings no cost to the school. Children covered under Medicaid accumulate no personal expenses for the dental services; furthermore, the program works with a non-profit agency to provide care for uninsured children.

References
Agency for Healthcare Research and Quality. (1996). Improving health care for rural populations. Retrieved April 03, 2011, from http://www.ahrq.gov/research/rural.htm
Agency for Healthcare Research and Quality. (2003, June). Children’s dental care access in medicaid: The role of medical care use and dentist participation (Issue brief No. 2). Retrieved April 3, 2011, from http://www.ahrq.gov/chiri/chirident.pdf
Agency for Healthcare Research and Quality. (2010). 2010 National healthcare disparities report (Rep. No. 11-0005). Retrieved April 3, 2011, from http://www.ahrq.gov/qual/nhdr10/nhdr10.pdf
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Hwang, E. (2008). Oral health disparities in rural us children (Unpublished master's thesis). University of Pittsburgh. Retrieved April 03, 2011, from http://etd.library.pitt.edu/ETD/available/etd-12042008-211420/unrestricted/hwange_etd_2_2008.pdf
International Association for the Study of Obesity. (2010, July 13). Success of community interventions for childhood obesity varies depending on the target age group. Science Daily: News & Articles in Science, Health, Environment & Technology. Retrieved April 03, 2011, from http://www.sciencedaily.com/releases/2010/07/100713091317.htm
Jackson, D. M., Jahnke, L. R., Kerber, L., Nyer, G., Siemens, K., & Clark, C. (2007). Creating a successful school-based mobile dental program. Journal of School Health, 77(1), 1-6. doi: 10.1111/j.1746-1561.2007.00155.x
Jones, S. (2003). Economic impact of the common cold. Ezine Articles. Retrieved April 03, 2011, from http://ezinearticles.com/?Economic-Impact-Of-The-Common-Cold&id=641088
Mattingly, M., & Stransky, M. (2010, Fall). (Issue brief No. 17). Retrieved April 4, 2011, from Carsey Institute website: http://www.carseyinstitute.unh.edu/publications/IB-Mattingly-childpoverty10.pdf
McKenzie, J. F., Pinger, R. R., & Kotecki, J. E. (2008). An introduction to community health. Sudbury, MA: Jones and Bartlett.
National Association of County and City Health Officials. (2010). First things first: Prioritizing health problems [Scholarly project]. Retrieved April 03, 2011, from http://chfs.ky.gov/NR/rdonlyres/B070C722-31C1-4225-95D5-27622C16CBEE/0/PrioritizationSummariesandExamples.pdf
National Rural Health Association. (2005, April). Meeting oral health care needs in rural america. Retrieved April 03, 2011, from http://www.ruralhealthweb.org/index.cfm?objectid=3FA06195-1185-6B66-883263BC28ABA0A4
ReachOut America. (2005). School Programs. ReachOut Healthcare America: The nation's leader in mobile dentistry and dental programs for children, military and business. Retrieved April 03, 2011, from http://www.reachouthealthcare.com/Mobile_Schools.htm
Skelton, J. A., Cook, S. R., Auinger, P., Klein, J. D., & Barlow, S. E. (2009). Prevalence and trends of severe obesity among us children and adolescents. Academic Pediatrics, 9(5), 322-329. doi: 10.1016/j.acap.2009.04.005
United States of America, Census Bureau. (2009). American fact finder. Retrieved April 4, 2011, from http://factfinder.census.gov/servlet/ACSSAFFFacts?_event=Search&geo_id=&_geoContext=&_street=&_county=Donalsonville&_cityTown=Donalsonville&_state=&_zip=&_lang=en&_sse=on&pctxt=fph&pgsl=010