An attempt to meet all of the community’s oral health care needs would be noble, but ultimately, unfeasible. Therefore, it necessary to identify the needs that are of highest priority for the community. Determining health priorities helps direct resources to the programs that matter most to communities. The process of prioritizing needs is best accomplished by a group of stakeholders who have reviewed the analysis of assessment data, understand the issues, and are knowledgeable about the community. There will undoubtedly priorities at odds with one another in the community. To differentiate among competing priorities, it is useful to establish criteria or guidelines for use in discussions about priorities. Certain criteria can be used to help make decisions about priorities. For example, assessing the feasibility and impact of addressing the problem, and correlate the two would make the decision easier. Also, assessing and comparing the perceived size or extent of the problem (e.g., how many individuals are affected), the seriousness of the problem, and the feasibility of implementing evidence-based interventions that will result in improved outcomes. Indicators can also be utilized to compare local oral health care to the national oral health. Whenever prioritizing needs, utilizing a framework can be helpful. The suitableness, legality, economics, acceptability, and resourcefulness all must be taken into account.
Finally, it would be prudent to consider a review of current best practices; this can provide essential information and guidance about interventions that are effective in actual practice, including information about the effectiveness of emerging interventions–in this case it would be application of occlusal sealants on permanent molars in children at moderate to high caries risk. B. Plan for Integration of Cultural Competence Given the ever-increasing diversity of America’s population and documented evidence of the significant disparities in health outcomes experienced by various population groups, an essential component of program planning is cultural competence. Striving to achieve cultural competence is a dynamic, ongoing, developmental process that requires a long-term commitment. Cultural competence must be considered at the health-services-system, organizational, and program levels. Cultural competence must be integrated into policymaking, infrastructure building, program administration and evaluation, and delivery of services. This integration of cultural competence requires a review of mission statements; policies and procedures, administrative practices; staff recruitment, hiring. and retention practices; professional development and in-service training, translation and interpretation processes, family/professional/community partnerships; health care practices and interventions addressing racial/ethnic health disparities and access issues; health education and promotion practices/materials; and community and state needs-assessment protocols.
At the individual level, cultural competences necessitate an examination of one’s own attitudes and values, and the acquisition of the values, knowledge, skills, and attributes that allow an individual to work appropriately in cross-cultural situations C. Design the Program I. Identify Desired Outcomes Once priorities have been established, the next step is to consider how they will be addressed. It may be useful to determine the terms to be used and then to ensure that everyone shares a common understanding of the meaning of these terms. Terms that could be used and should be understood include: dental sealants, dental caries, cavities, decay, occlusal fissures and pits, risk assessment, high risk patients, oral hygiene instruction, etc. Regardless of which terms are used, it is essential to work through and obtain agreement on desired goals with regard to the goal’s priority, the outcomes that must be achieved to meet the goal, what interventions or activities are needed to achieve outcomes, and how to measure the effectiveness of activities and evaluate achievement of outcomes. Objectives or outcomes must be specific, measurable, attainable, reasonable, and timely. Recommendations for school-based sealant programs include indications for sealant placement, i.e. seal sound and non-cavitated pit and fissure surfaces of posterior teeth, with first and second permanent molars receiving highest priority. It also includes tooth surface assessment including the ability to differentiate cavitated and non-cavitated lesions (unaided visual assessment is appropriate and adequate; dry teeth prior to assessment with cotton rolls, gauze, or, when available, compressed air; an explorer may be used to “gently” confirm cavitation (i.e., breaks in the continuity of the surface); do not use a sharp explorer under force; radiographs are unnecessary solely for sealant placement; and other diagnostic technologies are not required.
Finally, sealant placement and evaluation should include cleaning the tooth surface, using four-handed dentistry where resources allow, sealing teeth of children even if follow-up cannot be ensured, and evaluate sealant retention within one year. The Community Preventive Services Task Force recommends school-based dental sealant programs based on strong evidence of effectiveness in preventing caries in children. A 2013 Cochrane Collaboration review of sealant studies found that sealant placement on the occlusal surfaces of the permanent molars in children and adolescents reduces caries by 81% when compared to no sealant when followed up to two years. The following table illustrates the relationships between interventions, performance measures, outcomes, indicators, and results: Intervention Performance Measures Outcomes Indicators Desired Results Activity designed to achieve desired outcomes Measures of the effectiveness of the intervention activities Changes that, when combined, achieve the desired result Measures that quantify achievement of outcomes Change in well-being of target audience Placement of dental sealants on occlusal surfaces of permanent molars Number of teeth safely and effectively sealed Assessment of dentition following sealant placement shows a decreased prevalence of caries Number of students who received and retained sealants over time An overall decrease in prevalence in occlusal pit and fissure caries in children living in rural Indiana II. Identify Funding Resources An essential component of planning is identifying and mobilizing needed resources. It is critical to determine what is genuinely feasible—financially, programmatically, and politically.
Therefore, it is important to establish a projected budget for needed resources before conducting a search for resources. According to their own public website, the Indiana Dental Association is dedicated to the dental health of its state’s citizens and offers low cost dental care, emergency care, and resources for children. This would be a great organization to partner up with as part of our sealant campaign. The Indiana State Department of Health sounds more politically-oriented, but it too expresses its support of the oral health of Indiana’s population. It’s vision statement is to “improve the oral health of the people on Indiana” with the mission of “promoting and providing essential public health services to improve the oral health of the people of Indiana.” They would be an excellent source of state-approved funding for an early childhood sealants program in rural Indiana. Their aims are the following: measure the burden of oral diseases; decrease the burden of oral diseases; improve existing and new partnerships; and improve operations and policies. In 1981, Congress authorized the Preventive Health and Health Services (PHHS) Block Grant. The grant offers autonomy and flexibility to tailor prevention and health promotion programs to their particular public health needs. It supports activities like offering funds to critical prevention efforts to address specific health issues (e.g. untreated dental decay) that lack categorical state funding. There are also countless community service organizations that, if able, would be happy to devote a portion of their resources to the advancement of oral health of Indiana’s young, rural population who oftentimes have a lack of access to care. The Indiana University School of Dentistry would also be a great place to seek support and funding for the childhood sealant initiative. Another critical source of financial support is health insurance reimbursement, including that available from both private and public programs such as Medicaid and SCHIP.
Medicaid is a significant source of funding for oral health services, especially for children and adolescents. III. Review Best Practices In developing, integrating, expanding, or enhancing community oral health programs, it is useful to build on or tailor work that others have already done. Best practices are strategies or programs that have been shown to be effective in addressing a particular problem, with a particular population, in a particular place. A best practice in one environment may not be a best practice in another, and the strength of the evidence base for best practices varies. However, a review of what others have found effective can increase the portfolio of options for addressing a community’s oral health needs. The term ‘Best Practice Approach’ is intended to emphasize there is more than one ‘best’ implementation strategy that may produce successful outcomes. The context of individual state and community programs, and the environment in which they are developed and implemented, may impact whether an implementation strategy is successful. Variables to consider are: leadership, political acceptability, available resources, feasibility, and implementation constraints that are specific to a program’s environment.
These variables will influence the acceptability and adaptability of best practice approaches. Local oral health program administrators must be able to evaluate effective and cost- effective service delivery for oral health programs. Program needs range from deciding how best to invest limited resources, selecting which community based prevention programs to implement, how to improve effectiveness and efficiency, how to develop policies for a wide breadth of health services for which they may be unfamiliar. Based on recommendations and reviews by a panel of experts supporting the Task Force on Community Preventive Services, the Guide to Community Preventive Services (The Community Guide) strongly recommends school-based and school-linked dental sealant delivery programs for preventing or reducing occlusal caries on posterior teeth of children. Dental sealant programs generally are targeted to vulnerable populations less likely to receive dental care that could benefit from sealants, such as children eligible for free or reduced-cost meal programs. Schools are an excellent place to reach children and bring “access to care” to them all as a group. School-based programs are conducted completely within the school setting, with teams of dental health professionals such as dentists or dental hygienists utilizing portable equipment or in a fixed clinical facility within the school setting or in a mobile dental van parked on school property. School-based dental sealant programs seek to ensure that children receive a highly effective dental prevention service through a proven community-based approach. Tooth decay disproportionately affects low-income children and children from racial and ethnic minority groups. School-based sealant programs generally are designed to maximize effectiveness by targeting schools with high-risk children (those vulnerable populations less likely to receive dental care) such as children eligible for free and reduced-cost meal programs.
