Career Opportunities in School-Based Health Centers

By Terri Patrick, RDH, MS, CHES

Dental hygiene is expected to be one of the fastest growing occupations through the year 2012, according to the Occupational Outlook Handbook, U.S. Department of Labor, Bureau of Labor Statistics. This may be due in part to the growing opportunities for Registered Dental Hygienists in Texas to utilize their expertise in community health programs providing preventive oral health services to the underserved. The ability of hygienists to provide direct services to patients is an economical and viable way to increase access to care.

Rex Law, DDS and Sherry Jenkins, RDH share their experiences in teledentistry and school-based dental hygiene practice in their respective programs, both of which began in 2002. These programs in Northeast and South Central Texas address a critical dental need in the children's oral healthcare crisis.

Dr. Law, along with Dr. Lars Folke from Baylor College of Dentistry established a teledentistry pilot program in Pittsburg ISD (northeast Texas) for grades pre-K through 2nd grade. The goal was to provide preventive care for those children that had no means of obtaining dental care. The project was funded by the Baylor Oral Health Foundation and the Center for TeleHealth in Dallas. Angie Dunavant, RDH of Rockwall provides preventive instruction, prophies, fluorides, and sealants. She uses the intra-oral camera to record and store images to communicate with the dentists regarding the children's dental care. Parents are notified of dental problems as a result of the collaborative exam and given a choice of dentists to treat them. No fees are charged or billed to patients, insurance or government programs. Future plans with this preventive program include nutritional counseling to help combat the childhood obesity problem so common in our state.

Vicki Rockett, Principal at Pittsburg Primary School thanked Dr. Law for bringing first-time dental care to hundreds of economically disadvantaged children whose families cannot afford dental care. She said, "Having this service offered on campus allowed young children to receive treatment in a familiar atmosphere without the anxiety that often accompanies their first visit to the dentist." Too often an economically disadvantaged child's first dental visit is a result of a serious dental complication because of lack of preventive and early dental care.

The main challenges that Dr. Law's program incurred are listed below and the remaining information about this program is in Dr. Law's words:

"1. Funding 2. Funding 3. Funding --- we are very thankful for Baylor's Telehealth Center in Dallas assistance. Other obstacles that could occur when setting up a school-based clinic would include the cooperation of the school system, the tech expertise of the hygienist and dentist, quick access to tech support when a computer glitch occurred.

"In my opinion, the school district should not be mandated to fund the clinic. It could be sustained in a couple of different ways. At one point in time, there was a school program called SHARS --- School Health and Related Services. This program basically reimbursed the school

districts with funds when medical care (included giving kids their daily medication) was provided to Medicaid eligible special education students. If only 35-40% of children are accessing dental Medicaid, would it not make sense to go to the kids with the care? Would it not also make sense to reimburse school districts for the care provided to students to cover the school district's expenses in setting up a clinic and keeping it supplied and staffed? If school districts are allowed to employee nurses, should they also be allowed to employee dental hygienists??? Some dentists are afraid of losing patients; I don't see it that way. The things I see happening would all be win/win --- for the dental office and the patients. With the school hygienist detecting cavities and space problems, the dentists would be doing much more restorative/orthodontic type work --- instead of it going undetected on patients that would not be seen in dental offices anyway.

"Maybe many of us in the profession may need to re-evaluate the definition of preventive dentistry. My understanding of that term has always been the prevention of dental disease NOT the prevention of access to dental care as a result of a child's life circumstances.

"To those of you that have taken the time to read the best-seller "Purpose Driven Life", I ask you to go back and re-read the first sentence in the book. It is only 4 words -- but those words have profoundly affected my perception of life. Hopefully they will affect you the same way. Those 4 words ---'It's Not About You.' We in the dental profession should take those words to heart."

Sherry Jenkins' involvement with Methodist Healthcare Ministries began when a grant was received to start the school based dental program. The population receiving these services are school-aged children and their siblings 19 years of age and younger. In addition to clinical dental hygiene services, this program includes adult education for the parent, teacher and other school personnel as well as mouth guard fabrication for student athletes. Sherry has a bachelor's degree in Healthcare Administration, but believes her experience as a public health dental hygienist was most helpful in preparing her for her current position.

I asked her a few questions to learn more about her role:

What personal or professional skills are necessary or advantageous in this role?

Sherry: Being able to plan, organize, implement and evaluate programs. Organizational skills are a must. Everyday I may be doing different tasks or projects, which I enjoy. Every day brings new challenges. I am very good at keeping my schedule on a palm pilot so I can be aware of what needs to be done when. I usually have clinic on Tuesdays and Thursdays but that is the only days I have a set schedule, to some degree. I could be doing anything from ordering supplies, to meeting with teachers to set up oral heath education programs, to conducting screening projects or providing dental sealants at an off site school with portable equipment. We compile reports, papers, and posters from the data gathered.

How would you suggest interested Registered Dental Hygienists prepare themselves for a position such as yours?

Sherry: Learn as much as you can about public health dental programs either through education or experience. Read about these programs on the Internet. Don't be afraid to ask until you find the answer.

Do you feel your program would benefit other areas of the state if it was implemented in other areas?

Sherry: Yes but mobile units and portable equipment are an economical alternative to the more costly fixed operatories. Our program helps address the access to care issue for people in rural areas where access is an issue. I think using dental hygienists to run these programs and contracting or part time dentists works well.

Are there current laws or SBDE rules that prohibit your program from operating to its best ability?

Sherry: Even though our program is not a Medicaid provider yet (we are working on it), dental hygienists not being able to bill Medicaid for services provided can be prohibitive. Also HB 1285 which requires the parents of Medicaid patients to be physically present at the dental visit to be able to bill Medicaid can be a problem but certain situations such as school based dental clinics are exempt. The restriction of having a dentist examine the child on an annual basis before the dental hygienist can provide services can also be a problem for public health programs.

What challenges do you see in program sustainability?

Sherry: Our program is very lucky to be run by Methodist Healthcare Ministries which is able to sustain it. We have tried to become Medicaid providers and have run into a few problems. We are currently in the process of signing contracts with each school district so we will look like a school based health center by Medicaid definition. When we started the process of applying to become Medicaid providers nobody knew how to classify us on the application since we are not a part of the school district, so we were told we needed to have contracts with the schools to officially be considered a school based clinic and not a health center. Getting the designation as a school based clinic is important because of HB 1285 which will exempt us from having the parents of Medicaid children present for services billed.

How do you see the provision of preventive dental health care delivery changing in the next decade?

Sherry: A concept that is very interesting to me is that of Advanced Dental Hygiene Practioner. I work with Nurse Practioners in the school based health center and see what it has allowed them to do. I think having Advanced Dental Hygiene Practioners could open up the scope of practice in the field of dental hygiene and allow us to provide more preventive services without all the restrictions that we now have on the practice of dental hygiene.

Approximately how many people have you served?

Sherry: Total clinical visits for two days a week for three years is 1,706, which was billed on a sliding-fee schedule. Free services provided include:

1210 screenings 426 students provided dental sealants

547 students participating in weekly fluoride mouth rinse program

2,340 students provided classroom oral health education

174 student athletes provide mouth guards

In addition many presentations were provided to teachers, school boards, parents and other school employees.

Please tell us anything else about your position/job that you would like to share.

Sherry: The support from the University of Texas Health Science Center Dental and Dental Hygiene Programs and Methodist Healthcare Ministries has been vital to our success. Having a great team to work with at the school based health center has been a significant bonus. Working with nurses, social workers and office staff who value our dental program has been great. We could not have done all that we have without the vital support from Methodist Healthcare Ministries which has been awesome.

Sherry shared some success stories of children who were helped by her program:

A patient in middle school who was very scared of any type of medical or dental procedures involving injections has had some necessary dental treatment successfully performed. The patient has had numerous medical procedures including a feeding tube that made him very apprehensive of any type of medical or dental procedures. Dr. Jim Thrash has been working with this young man and doing some desensitizing to help him become more comfortable with dental treatment. The patient had 4 sessions of desensitizing and has had an exam, prophy and a temporary filling placed. Because this was in a school setting we had time to work with this young man to alleviate substantially his fears. This type of appointment would not likely be performed in a regular dental setting.

MHM staff does a great job of referring patients to the dental program. Our Pediatric Nurse Practitioner referred a child who was from Mexico and was new to Marion ISD. The child had an appointment made with Dr. Thrash and all necessary treatment was performed. Having a pediatric nurse practitioner who is very interested in the child's oral health (she even did a project in nursing school on oral health) has been a tremendous benefit.

Student athletes at Marion ISD have been giving positive feedback on the custom mouthguards. They relate to us how comfortable the custom mouthguards are and that they can even talk well with them in place. This was important to one young man who plays center on the 8th grade football team because he has to call plays.

Texas, like many other states had severe budget cuts. The CHIP dental coverage was completely eliminated as a result of the budget cuts. We see children in pain due to decay of their teeth every week. Parents of one 12 year old boy who had a root canal were very grateful we could save his tooth without an extraction. Due to our sliding fee schedule the boy and his parents had an option other than extracting his tooth which was a permanent molar. One small step at a time we are educating parents as to the importance of the teeth and how a healthy mouth makes our whole bodies healthier. Parents hear the importance of this message when they don't feel bad about not having the money to treat the problem. We also had another parent come to our office specifically to go over the treatment their daughter needed. This child needs a lot of dental work and I was glad we had the time to spend educating these parents about the needed dental care. This case again was parents who could not have financially afforded the treatment in a general dental office. It is very important to educate parents when the opportunity arises and in this situation we have been able to spend the time needed to do this, even if it is done over the phone.

A little girl had a toothache and because of the digital x-ray the dental hygienist was able to see her, take an x-ray and e-mail it to Dr. Thrash at our other site. Dr. Thrash was able to see the child had a large carious lesion that was forming an abscess. He prescribed antibiotics for the child. She was seen 10 days later by Dr. Thrash and had the tooth extracted. This case was a classic example of how having a school based dental clinic helps children who otherwise would have no way of getting to the dentist. We could pull her out of school since her parents could not bring her. Having access to a dental clinic at school helped this family have access to dental care which otherwise they could not have. We have seen several other cases in which the child would have not been able to go to a dental office 15-20 miles away. We have been getting a number of referrals from the social worker with the "Communities In Schools" program who helps children in these types of situations.

Another successful school-based and teledentistry program is found in the Lyford Independent School District in South Texas. Online telecommunications are used to evaluate patients and prescribe additional services as needed. The preventive services the RDH provides are designed to reduce the number of absentees and keep students in school, while combating the soaring medical costs of a dental problem left untreated. Approximately 87% of the students are economically disadvantaged and otherwise would not seek the services of a dental professional until a serious condition occurred.

To learn more about the Advanced Dental Hygiene Practitioner see www.adha.org.