• Registered Dental Hygienists (RDHs), Registered Dental Hygienists in Alternative Practice (RDHAPs), and Registered Dental Hygienists in Extended Functions (RDHEFs)
• Registered Dental Assistant in Extended Functions (RDAEFs) can also perform oral health assessment in school-based programs and community health settings under the supervision of a dentist, RDHAP, or RDH (RDAEF BPC Sec 1753)
• School nurses or nurse practitioners who are trained to perform dental screenings; however, they cannot perform KOHA. This pocket guide resource for screening is a valuable oral health screening resource for school nurses.

Dental providers can be recruited for the screenings through:

• Community clinics such as FQHCs
• Private practitioners in the community
• Dental schools and dental hygiene schools
• Private organizations offering mobile screening services
• Dental societies

The equipment and supplies listed below are the minimum necessities for a school-linked screening program. The requirements vary based on the structure of the program and the extent of services provided at the school site.

Existing school-linked dental programs intending to expand services to include other preventive services such as fluoride varnish and dental sealants will require further equipment and supplies based on the model of the program. Further information on setting up a school-based dental sealant program is available at SEAL America and the COHTAC Resource Center.

1. Personal protective equipment (PPE)

The use of appropriate PPE is recommended throughout the entire screening process. The screening team must follow the local and state dental society guidelines to wear the appropriate PPE during the dental screening process. PPE are special coverings designed to protect dental health care personnel from exposure to or contact with infectious agents. These include gloves, face masks, protective eyewear, face shields, and protective clothing (e.g., reusable or disposable gown, jacket, and lab coat). Screeners should wear appropriate face masks (e.g., surgical, N95 based on CDC or OSHA’s guidelines) during screening.

Gloves must be changed after every student and after disinfecting surfaces. Hands should be sanitized using alcohol-based hand disinfectant before wearing gloves.

2. Set up and infection control

The screening area should be determined in advance of the screening day. A well-demarcated area for clean instruments and disposable supplies within reach must be identified. A lined trash can must be placed away from the clean supplies to collect used and contaminated disposable mirrors/tongue depressors and soiled PPE. A tray table should be set up beside the screening chair to hold the items needed for each screening: disposable mouth mirror and/or tongue depressor on a clean paper towel/napkin. After each screening, the surface must be disinfected prior to placing a new paper napkin with mirror/tongue depressor for the next student. Preferably a separate table to hold paperwork/laptop/tablet should be conveniently positioned. Standard precautions for infection control must be observed when other components of preventive dental services are provided in combination with the dental screening. A biomedical disposal setup may be required depending on the additional services provided.

Equipment and supplies exposed and not utilized during the screening process must be considered contaminated and should be disinfected or discarded appropriately (see National Association of the School Nurses - NASN).

The tray table or any contaminated area must be disinfected appropriately between students. The List N Tool on the EPA website can be referred to for the list of EPA-registered disinfectants.

When reusable instruments are utilized, a receptacle must be used to collect contaminated instruments. Care should be taken while transporting contaminated instruments to prevent any exposure, injury, or cross-contamination.

3. Hand hygiene

On average, a visual dental assessment by an experienced dental provider requires 1-2 minutes per student. When scheduling, providers should take into consideration the time needed for documentation, disinfection, and set up for the next student.

Manage time efficiently to ensure a smooth flow of the day. Tips to manage time:

• The dental team must collaborate with school administration/ assisting staff to create a protocol jointly.
• Plan the workflow for the day identifying the team members for the various tasks such as walking the children to and from the clinic area, documentation of findings, set up, and break down.
• Obtain from the school a roster of students including those that have opted out of the screening.
• Ensure that classroom teachers are aware of the detailed plan for the day so that they can prepare students for the screening process and provide the necessary logistical instructions as far as where the screenings will be done, how many students at a time will leave the classroom, staff accompanying them and how long it will take.

• As the student proceeds towards the screening area, observe facial symmetry for any extraoral swellings/abnormalities.
• Inquire if the student is experiencing any pain or discomfort in the mouth. If the student complains of any discomfort, gather information on the onset and duration of the discomfort. Inspect the area of concern.
• Inspect extraoral tissues for any palpable swelling or tenderness.
• Inspect intraoral tissues for swelling, bleeding, redness, decay, and for the presence of abnormalities. Lift the lip to clearly visualize the buccal gingiva for early signs of decay, plaque around the gums, and abscesses.
• Document findings and appropriate treatment urgency level as outlined in the screening form.

As the student receives a dental assessment, the dental team member assisting the screener will document the findings. The findings are recorded on the oral assessment form, as well as a form that goes to the parent/guardian using simple, easy-to-understand language. The report to the parent should include the assessment results, the instructions for next steps, information on oral health best practices and other terminology used in the screening result as indicated, and active consent forms if treatment is indicated that can be offered in the school setting (such as sealants, prophylaxis, fluoride varnish application). If a need for urgent dental care is identified, the report must include a list of providers that can be contacted to access immediate care. Information on care coordinators can be included if available.

Data from the screenings should be compiled and made available for analysis. All data gathered must be handled confidentially.

Determining the urgency level is the most important goal of the oral health screening. Based on the results, care coordination efforts can be prioritized for the most urgent cases. Below is the description of the three treatment urgency levels as per the screening form:

Level 1 - No obvious problem found. Preventive care with complete oral evaluation is recommended.

Level 2 - Caries without pain or infection; and/or child would benefit from sealants or further evaluation. Early Dental Care Recommended.

Level 3 - Detected pain, infection, swelling, soft tissue lessions. Urgent Care Needed.

Oral health counseling can be provided by engaging existing community assets such as promotores/community health workers who can also assist with dental referrals and care coordination. If such resources are not available, the LOHP can facilitate the training of certain school staff, school nurses, or members of the dental team to provide oral health counseling. Training on communication strategies and motivational interviewing provides counseling staff with the knowledge, attitudes, and skills needed to enhance families’ confidence and reduce their apprehensiveness to change.

Oral health counseling can be offered in the following settings:

1. One-on-one: students assessed with an urgent/early dental need and their families can be contacted by a school nurse or dental care coordinator to report on oral health assessment findings and provide oral health counseling.
2. Group setting: oral health counseling is most effective one-on-one, but some components of oral health counseling, such as prioritizing oral health, goal setting, and addressing barriers, can be utilized in a group setting such as presentations at an auditorium or classroom. Parents and caregivers can be engaged at school health fairs and back-to-school nights. The sessions should be interactive with group activities and allow the group to share their concerns and provide feedback. Session handouts with resources to promote oral health and guidance to goal setting must be made available at these sessions.

Motivational interviewing is a patient-centered counseling approach that can be utilized to support and empower students and families through empathy and concern. Motivational interviewing involves gaining cooperation by creating a supportive environment to address the barriers to changing behavior through more listening and less confrontational communication.

Motivational interviewing can be employed for oral health awareness and education, personal goal setting, motivating parents to access care, and increasing commitment to treatment follow-up.

Resources for motivational interviewing:

• Motivational Interviewing Example: Avoiding Traps In A Dental Visit
• Brief Motivational Interviewing in Dental Practice
• Motivational Interviewing: 4 Simple Techniques for Hygienists
• Motivational Interviewing: Patient-Centered Behavior Change
• Motivational Interviewing: A Patient-Centered Approach to Elicit Positive Behavior Change

The mouth:

• Parts of the mouth: a brief introduction to baby teeth, adult teeth, gums, tongue
• The function and importance of the different parts of the mouth

Oral hygiene habits:

• Brushing: the purpose of brushing, technique, duration, type of toothbrush, amount of fluoride paste
• Flossing: the purpose of flossing, technique, type of flossing aids, and frequency
• Rinsing: after brushing and after snacking

Dental decay:

• What is dental decay, its cause, and how to avoid it

Dietary considerations:

• Foods and drinks that are good/bad for teeth
• Examples of healthy snacks and foods that cause cavities

Visiting the dentist:

• Promote the habit of visiting the dentist regularly, address any feelings of anxiety about seeing a dentist

Fluoride varnish and/or sealants (if offered in addition to the screening):

• What it is, the benefits, how it is applied, what to expect when you receive it

Some useful resources for oral health education:

• Elmo’s Toothy Dance video
• Sesame Street Tooth Friendly foods
• ADA presentations and resources
• Smile, California: brushing technique and additional resources
• Smile, California: toothbrushing calendar
•  CDPH flossing
• Sesame Street in Communities