Research Papers

Texas Public School Nurses’ Assessment of Children’s Oral Health Status Jill Peterson, Linda Niessen, G.M. Nana Lopez

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ABSTRACT: Researchers investigated the amount and types of dental morbidity that Texas public school nurses observed in an aver- age school week. Two thousand nurses were randomly selected and surveyed by mail with 54% responding. Respondents reported 3.5% of the student population sought the nurses’ services for a dental problem. Twelve school nurses reported that, of all health problems they observed, more than 50% were dental-related. Approximately 48% indicated oral health screenings occurred at least once every other year. Data suggest children are suffering dental problems that could possibly be detected and treated by oral health screenings, thus preventing more serious morbidity. As part of the Texas public school admissions protocol, like required immuniza- tions, children suffering dental problems could be referred for preadmission oral examinations to identify early any dental problems. and thus improving the children’s oral health and preventing school absenteeism. (J Sch Health. 1999;69(2):69-72)

ood health is vital to a child’s ability to learn and G succeed in life.‘ Despite the high prevalence of dental decay in the United States, dental morbidity is not consid- ered a serious public health problem by policymakers because it is generally chronic, not life-threatening, and typically has acute stages of short duration.2 If a child is suffering pain from a dental problem, it may affect the child’s mental and social well-being at school, and school attendance. National Health Interview Survey data during 1985-19863 estimated 51 million hours of school were missed annually by children as a result of dental pain and visits to dentists for treatment. Reisine’ noted that when acute dental problems are treated and children are free from pain, they become more actively involved in their educa- tion, improving learning and attendance records.

School nurses play a critical role in identifying children with oral health problems and in need of dental care. According to the Texas Association of School board^,^ a child must be screened for vision, hearing, growth, and scoliosis, yet a dental screening is not required or performed on admission. In 1991, the US Dept. of Health and Human Services stated that “poor children are four times as likely as more affluent children to miss school because of their ailments. Upper respiratory infections, dental decay, allergies, injuries and skin disorders are frequent ailments of poor children.”’ In 1984, the National Institutes of Health reported 16 acute dental conditions per 1,000 (16/1,000) persons in the United States. Thus, dental conditions are equally as prevalent as headaches (17/1,000) and more prevalent than pneumonia (12/1,000) and eye conditions (14/1,000).

Jill Peterson, DDS, MPH, Dept. of Biomedical Sciences, Baylor College of Dentistry, P.O. Box 660677, Dallas, TX 75266-0677, o r <jpeterson@tambcd.edu>; Linda Niessen, DMD, MPH, MPP, Professor, Dept. of Public Health Sciences; and G. M. Nana Lopez, DMD, MPH, Assistant Professor, Dept. of Public Health Sciences, Baylor College of Dentistry, P.O. Box 660677, Dallas, TX 75266-0677. This article was submitted June 3. 1998, and revised and accepted f o r publication November 20, 1998.

This study identified the amount and types of dental morbidity school nurses manage in children. A survey of school nurses organized by Texas counties defined the school nurses’ range of experience in diagnosing oral prob- lems and their educational needs in this area. This survey provides better estimates of oral health needs by county so that interventions can be developed to improve the oral health of the Texas school children.

SURVEY METHODS Researchers developed and pilot-tested the survey in

September 1996 to identify the rate and types of dental morbidity, and the experience and education of the report- ing school nurse. To examine differences resulting from lack of the availability of dental professionals, school nurses responses were categorized as Dental Health Provider Shortage Areas (DHPSA) or non-DHPSA. Distribution of dental providers across geographic areas contributes to the consumers’ ability to obtain oral health care. The US Dept. of Health and Human Services devel- oped the DHPSA designation system to measure availabil- ity of dental health care professionals across a designated area. The system serves as a mechanism for identifying areas with less than an adequate number of dentists. The degree of shortage experienced by residents of a geographic area is measured using the ratio of population per dent i~t .~ An area with a population to fulltime equivalent dentist ratio of greater than 5,000 to 1 is designated as having a shortage of dental personnel and labeled a DHPSA.

Questionnaires were mailed to 2,000 school nurses selected randomly from a list of 4,222 school nurses regis- tered by the Texas Education Administration on 6,347 school campuses. Surveys were mailed in December 1996. A cover letter accompanied the survey signed by the dental director of the Texas Dept. of Health and the past president of the Texas Association of School Nurses. Directions were given for school nurses to complete the survey and return it in an enclosed, preaddressed, stamped envelope. In four weeks, 1,083 surveys were returned. According to the

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Journal of School Health February 1999, Vol. 69, No. 2 69

power analysis, 392 surveys were required to detect a 10% difference between rates of dental morbidity in DHPSA and non-DHPSA (a =.OS, p =.20, power =.SO). Thus, a follow- up mailing was determined not to be necessary.

Data were coded in Excel.@ Entries left blank by school nurses were not coded. Data validation was completed by checking entries randomly for 10% of the questionnaires and by checking for errors outside the expected range of values for each variable. If an outlier was isolated, the ques- tionnaire was re-examined and all data for that question- naire were re-entered and confirmed. Data were transferred to Minitab for statistical analysis.

Analysis by Minitab entailed simple descriptive statistics of the population demographics, amount and types of morbidity existing within the population, and the school nurses’ experience and education. A t-test was performed on the rate of dental morbidity between DHPSA and non- DHPSA.

SURVEY RESULTS Of the 1,083 nurses returning questionnaires, 325 nurses

were in a DHPSA and 758 respondents were in a non- DHPSA. Nurses represented 145 of 254 Texas counties (57%). Nurses from Houston (203 of 1,083, 18.7%), Dallas (104, 9.6%), Tarrant (91, 8.4%), Bexar (80, 7.4%), and El Paso (51, 4.7%) counties comprised 49% of the sample population. The surveyed sample of nurses in the urban community (49%) reflected the actual urban population (47.6%) of 17 million Texans who live in counties with more than 500,000 residents.

Fifty percent of school nurses worked inM elementary schools, 14.4% in junior high schools, 11.6% in high schools, and 12.6% in all grades. School nurses who reported serving multiple gradeslschools, such as kinder- garten and high school, comprised 10.2% of the sample. No difference existed in years of experience between school nurses working in DHPSA and non-DHPSA. School nurses with less than eight years of experience tended to work in the largest student populations. Size of the student popula- tion for whom school nurses were responsible ranged from 19 to 4,500 students. The average size school managed by each school nurse (or combination of school populations since some school nurses covered more than one school) was 944 students.

Table 1 Types of Dental Morbidity Reported by School Nurses

Rank Type of Morbidity

1

2

3

4

5 Orthodontic problems, crookedkrowded teeth,

Dental cavities, caries, decay, brownlblack teeth or rotten teeth Toothache, pain, wisdom tooth pain, swollen jaws, abscessed teeth Trauma or accidents, injury, broken teeth, chipped teeth, bit tongue or lip Gingivitis, bleeding gums, inflamed gums, infected gums, gingival abscess

wires broken

A representative sample of children from the elementary schools (50%) and middle schools (14.7%) were compara- ble to the general grade school population of Texas public school children. This survey under-represents early child- hood education (ECE), prekindergarten, and kindergarten (1.0%), and high school (11.9%). School nurses in group five, “All Grades,” served multiple schools, such as high school and ECEkndergarten groups or middle school and high school, within the same county which may account for the under-representation of the ECE and high school groups.

School nurses reported that within a school week, an average of 204 students sought their care for health prob- lems of all sorts, inclusive of medication disbursement. The total number of children seen by a school nurse within a week ranged from 0 to 1,000 students. On average the respondent nurses saw approximately 6.5 students per hour. A total of 7.2 dental problems contributed to the 204 total health problems within a week. Thus, 3.5% of the total health problems represented dental problems as seen by school nurses. This calculated percentage (7.2/204 = 3.5%) was validated by examining the school nurses’ reported percent estimate of dental problems to overall health prob- lems: 3.53%.

Figure 1 contains the number of school nurses reporting percentage of dental problems. Twelve school nurses reported that more than 50% of all health problems seen were dental- related. Of these 12 reports, three represented DHPSA counties on the Texas-Mexico Border: Hildalgo, Cameron and El Paso. Counties within the Houston metro- plex, Fort Bend, Harris (mentioned three times) and Liberty also were listed. The other counties were randomly distrib- uted across Texas: Dallas, Baylor, Borden, and Burnett.

Table 1 lists the type of dental problems observed by the nurses within a week. Different types of dental morbidity varied by different grade levels. For example, elementary school children suffered more toothaches and loose teeth than did high school students. Middle school and high school students were reported to have more periodontal problems/bleeding gums, hygiene problems, orthodontic complications (broken wires), and crooked teeth or maloc- clusion.

Figure 1 Number of Counties

Reporting Percentage of Dental Problems

Numberofmunues

I 2101 198

70 Journal of School Health February 1999, Vol. 69, No. 2

Approximately 48% of reporting school nurses stated that oral health screenings occurred at least once every other year. At least 31% of school nurses personally provided the oral health screening for incoming and enrolled students. Figure 2 shows the frequency in which school nurses perform oral screenings. Of the 31% of school nurses who personally performed dental inspections; 1 .O% inspected twice a year, 26.7% inspected annually, 3.6% inspected every other year, and 3.4% inspected every third year. Sixty-five percent stated they do not personally perform oral screenings. Nurses reporting more dental problems within their student populations tended to perform oral health screenings more often than those who did not perform oral screenings. If a child complained of dental pain, 99.5% of school nurses responded they would look in a child’s mouth to determine the possible cause of pain.

No significant difference occurred in the rates of reported dental morbidity between DHPSA and non- DHPSA. Though 12 school nurses reported greater than a 50% ratio of dental to health problems, and 58% of school nurses reported greater than 25% dental to health problem ratio, no statistically significant differences existed between DHPSA and non-DHPSA. Further, no statistically signifi- cant difference in caries frequency rates was noted between DHPSA and non-DHPSA and different grade levels of students.

Comments received from school nurses indicated oral screenings should be linked more closely with referral sources. School nurses pleaded to improve available resources so they could refer dental problems. Texas school nurses try to fulfill their mission to promote each student’s optimal level of wellness and educational potential without the resources to refer poor and sick children. A Dallas school nurse wrote, “Rarely does a dentist provide free services. We need more dental resources. It takes six months to have students evaluated. We need mobile vans to travel to schools in alternating periods.” A Houston school nurse mentioned, “The main problem at my school is money. The parents can’t afford to pay for any type of dental care. They have problems putting food on the table, so dental health comes dead last.” From a Pecos county

Figure 2 Percent of School Nurses Who Personally Perform Oral Health Screenings at Designated Frequency

I

80 I 1 1 70 I- 65.42 ] 1 60

50

a 40 2 30

20

10

0

c c

school nurse, “In rural areas, no dentist is available or will- ing to provide care. I would like to see a Texas Dental Health Department dentist yearly in my district.”

SURVEY IMPLICATIONS Dental morbidity accounted for 3.5% of all reported

health problems. Other health problems outnumbered dental problems managed by most school nurses. The low reporting of dental morbidity to the school nurse does not mean that dental problems do not exist within these popula- tions. Rather, the prevalence of dental disease is not normally distributed and large numbers of dental problems are occurring in a small number of communities. About 20% of school nurses stated they see at least one dental problem in a week, and 12 nurses reported that dental prob- lems accounted for more than 50% of all health problems they saw.

Texas has 99 DHPSA of which 79 (81%) are in rural areas and 84 represent entire individual counties5 Thus, individuals residing in a DHPSA usually must travel long distances to obtain dental care. The designation as a DHPSA assists the state in focusing resources in areas of need and to meet the demands of the public. Unfortunately, treatment needs are greatest among minority and lower socioeconomic classes of children6 and especially teenagers,’ groups most likely to live within DHPSA.

This survey examined the frequencies of dental morbid- ity in DHPSA and non-DHPSA. The results showed 12 nurses reported more than 50% of all reported health prob- lems being dental. Of greater interest is that 8 of these 12 reporting school nurses, were from five different non- DHPSA counties. Though these five counties were not clas- sified as underserved based on the DHPSA classification, school nurses reported an overwhelming number of dental problems within the student population. Based on these data, children suffering dental problems can live in commu- nities with a sufficient number of dentists as well as those communities that are dentally underserved.

School nurses reported a range of problems such as caries, gingival disease, malocclusion, loose teeth, and trauma. Different types of dental morbidity affect different grades levels. For example, elementary students were more likely to be affected by caries, toothaches, and loose teeth. Many middle and high school students were actively under- going orthodontic treatment and thus suffered problems with orthodontic appliances. Gingival disease was reported more often for high school students, which school nurses attributed to poor oral hygiene. Trauma and accidents ranked the same for all grade levels.

The Healthy People 2000 initiative established a national objective that “at least 90% of all children entering school programs for the first time to receive an oral health screen- ing, referral and follow up for necessary diagnostic, preven- tive and treatment services.” The survey found that approximately 48% of the school nurses ensure that oral health screenings occur at least once every other year. Texas is performing well below the national objective of 90%. To meet this objective by the year 2000, Texas needs to implement a statewide program to ensure that an oral health screening is provided for all entering students and that the necessary professional resources are available for referral. School nurses trained to perform oral examinations and currently do so on a regular basis, identified more

Journal of School Health February 1999, Vol. 69, No. 2 71

dental problems than school nurses who do not perform oral examinations annually.

The survey had several limitations. It measured the rela- tive frequency of dental morbidity indirectly through school nurses’ experience rather than measuring the number of children directly. These data represent sufficiently serious dental problems that caused the child such discomfort that a school nurse’s intervention was warranted. Thus, frequency of dental morbidity determined by this survey may underes- timate the frequency of true dental morbidity because not all children suffering from a toothache or dental pain report to the school nurse. In addition, other students may have seen the school nurse more than once for care of a persis- tent dental problem. To yield accurate prevalences and inci- dences of dental morbidity, a complete clinical and radiographic examination of the children by a dental professional is necessary.

Second, the frequency and types of dental morbidity were based on the school nurses’ recollection. Questionnaires captured the nurses’ estimation of dental morbidity without reporting actual numbers of students seen with exact types of dental problems listed. Completion of a daily log for one week would be the best approach to avoid the problem of inaccurate recollection. However, during the survey development, nurses indicated they would not have time to keep a log of dental problems.

The data herein suggest the need for implementation of an oral health screening tied to referral sources for all incoming students, similar to the requirement of immuniza- tions prior to starting school. An oral health screening prior to school enrollment, as suggested by Healthy People 2000, would help the state of Texas target children within the school system who suffer from dental problems and need immediate treatment. Presently, 48% of the sampled school nurses perform or arrange for a dental health care profes- sional to examine students. Some school nurses mentioned that their school districts have adopted a mandatory pre- admission dental screening, much like mandatory immu- nizations. This effort expanded statewide would have beneficial results.

While low-income children can receive dental services at no cost through Medicaid, many children and their fami- lies are unaware of this resource or do not use the benefit even when they know about it. Currently, 42% of Medicaid eligible children in Texas receive dental services.’ Unfortunately, many children are not eligible for Medicaid and their families do not have the resources to pay for dental services. These children present the greatest chal- lenge when trying to identify dentists to treat them. Local publicly and privately funded dental clinics exist through- out Texas. However, based on the findings of this survey,

these clinics do not sufficiently meet the many oral health needs identified by the school nurses. Collaborative efforts among school nurses, local dental societies, and local health departments could facilitate development of effective referral networks. Academic linkages between school nurses and dental and dental hygiene schools could assist in developing new models for educating dental and dental hygiene students and meeting the dental needs of some children.8 Possibly, dental morbidity within the public school population would drop if school nurses are actively intervening and have a referral source for children who need dental care.

CONCLUSION KOZO~’ observed, “children of the South Bronx live for

months with pain that grown ups would find unendurable.’’ Children of the South Bronx are not alone in suffering oral pain. Texas school nurses identified many school children with significant unmet oral health needs. Though oral diseases are preventable, once they occur, they do not resolve without dental intervention. Based on results from this survey, a need exists for the nursing and dental profes- sions to work together to develop interventions to reduce dental morbidity and improve the oral health of children in public schools throughout Texas.

References 1. Healthy People 2000. National Health Promotion and Disease

Prevention Objectives. US Dept. of Health and Human Services; Washington, DC: Public Health Service; 1991.

2. Reisine ST. Dental health and public policy: the social impact of dental disease. Am J Public Health. 1985;75(1):27-30.

3. Ries PW. Current Estimates From the United States National Health Interview Survey, 1984. Washington, DC: Public Health Service; USDHHS publication no. PHS 86-1584. 1986.

4 . School Nursing in Texas: Guidelines to Professional Practice. Austin, Texas: Texas Association of School Nurses; 1995.

5. Health Professions Resource Center . Dental Care Healrh Professional Shortage Area (HPSA) Summary Statistics for Texas: May 1996. Bureau of Community Oriented Primary Care. Austin, Texas: Texas Dept. of Health.

6. White BA. Toward improving the oral health of Americans: an overview of oral health status, resources, and care delivery. Public Health Rep. 1993;108(6):657-672.

7 . Texas Dental Association Council on Governmental Affairs. Dentistry: health care that works. A statement of policies of the Texas Dental Association. Texas Dent J . 1996;113(12);32.

8. Niessen LC. Future dental public health programs: forging commu- nity and academic collaborations. J Public Health Dent 1993;53(2):115- 118.

9. Kozol J. Savage Inequalities: Children in America’s Schools. New York, NY: Harper Perennial; 1992.

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