Using the Basic Screening Survey to assess the oral health of populations

1
Using the Basic Screening Survey to assess the
oral health of populations
A supplemental training to be used with the ASTDD
Manual

• Valeria Carlson, BS, MPH
• Deborah Bode-Hinson, RDH, BHS
• Christine Veschusio, MA, RDH
• Richard McDaniel, BS, DMD, MPH

2
Training Goals

• To give the audience an understanding of what the
  Basic Screening Survey is, how it is used, and
  what can be learned from it
• To provide screeners with specific examples of
  screening codes so that all results are
  consistent
• To check screener reliability before implementing
  the OHNA-2007 and
• To get feedback on how we can improve this
  training program

3
Training Objectives

• By the end of this training, participants will be
  able to
• Give 3 reasons why a surveillance program is
  important
• Define the appropriate terms (i.e. sealant,
  caries experience, etc)
• Conduct oral health screenings and get results
  that are consistent with professionally coded
  responses more than 80 of the time
• Correctly fill out screening forms and results
  forms
• Interpret results on forms filled out by others

4
Modules included in training

• Module 1 What is an oral health screening?
• Module 2 Choosing the sample
• Module 3 Supplies and organization
• Module 4 Administrative procedures
• Module 5 Screening Procedures
• Module 6 Screening checklist
• Module 7 What youre looking for and why
• Module 8 Practice
• Module 9 Common Conditions
• Module 10 Test

5
Module 1

• What is an oral health screening, and why do we
  do them?

6
The Importance of Surveillance

• Surveillance allows us to
• Take a snapshot of the states needs and assets
• Plan OH programs for the state
• Evaluate the effectiveness of existing programs

7
National and State Oral Health Goals
Data Sources Healthy People 2010 Chapter 21,
http//www.healthypeople.gov Centers for Disease
Control and Prevention DATA2010,
http//wonder.cdc.gov/data2010/
8
The Importance of Consistency

• With multiple examiners, it is essential that
  everyone screens the same way.
• Set diagnostic criteria are used because
• Everyone must follow the same criteria
• Same procedure used in all locations
• Consistent estimates of disease across locations

9
Data Sources for Surveillance

• BRFSS Behavioral Risk Factor Surveillance System
• HP2010 Data Healthy People 2010 Data Tracker
• NHANES National Health and Nutrition Examination
  Survey
• NHIS National Health Interview Survey
• NCHS National Child Health Survey
• BSS Surveys

10
What is the Basic Screening Survey?

• Created by the Association of State and
  Territorial Dental Directors (1970s)
• Non-invasive oral health screening
• Notes the presence of caries, fillings, and
  sealants estimates treatment urgency
• Done by medical or dental professionals

11
School Dental Prevention Programs
12
History of OHNA in SC

• 1982-1983 First OHNA done with random sample of
  children aged 5-17
• 2002 Repeated with K-5 and third grade students
  (not comparable to 1982 survey)
• 2007 Will repeat 2002 methods with same sample
  population (comparable to 2002 survey)

National sample is for 6 and 8 year olds (Our K-5
and 3rd grade sample is likely comparable will
test during analysis phase)
13
OHNA 2002 Results

• 52 of children had experienced decay (compared
  with 50 of children nationally)
• 32 of children needed dental treatment (compared
  with 26 of children nationally)
• 20 of children had at least one dental sealant
  (compared with 28 of children nationally)

14
Project Goals for OHNA 2007

• To establish the oral health status of South
  Carolina K-5 and third grade students through a
  comprehensive survey of caries experience,
  untreated caries, treatment urgency, and dental
  sealants
• To compare the results of this survey with the
  results from the comprehensive survey done on K-5
  and third grade students in 2002, in order to
  establish whether the oral health of South
  Carolina children has changed between the
  baseline survey and the current survey and
• To evaluate the effect of school dental
  prevention programs by comparing the oral health
  status of students who participate in those
  programs with the oral health status of students
  who do not participate.

15
OHNA 2007 will find

• Prevalence of untreated dental decay
• Prevalence of treated dental decay
• Treatment urgency for children who have untreated
  dental caries
• Prevalence of dental sealants
• Variation in dental status due to outside
  indicators (i.e. location, race)
• Status of kids in SDPP vs. kids not in SDPP
• Changes in the prevalence of dental conditions
  since OHNA-2002

16
Module 2

• How do we decide whos included in the survey?

17
Different Types of Sampling Framework

• Convenience Sampling
• Pathfinder Survey
• Simple Random Sampling
• Stratified Random Sampling
• Cluster Sampling
• Probability Proportional to Size Sampling

18
The Stratified Random Sample

• Say you have a pile of 100 coins 75 pennies and
  25 dimes. In a random sample of 40 coins, you
  could get any combination of coins, from 40
  pennies to 25 dimes and 15 pennies.
• In a stratified random sample of 40 coins,
  because the 75 pennies constitute 75 of the
  population, you would choose 75 of the sample
  (or 30 coins) from the pile of pennies and 25 of
  the sample (or 10 coins) from the pile of dimes.
• Thus, based on how common it is in the
  population, each coin has an equal probability of
  being included in the sample. This gives your
  sample more predictive statistical power.

19
The Benefits of the SR Sample

• Ensures that the sample represents the target
  population
• Allows greater statistical power in analysis

20
Stratifications Used in this Sample

• 618 schools with 102,628 K 3rd grade children.
• Within DHEC Regions
• Rural/Urban
• Free/Reduced lunch
• Large districts (gt 60 schools), 10
• Small districts (lt 60 schools), 6

21
Sampling Results

• A total of 39 school districts are included in
  the final sample.
• There are 73 schools in the final sample.
• All K-5 and 3rd grade classrooms from the sampled
  schools will be included in the survey
  population.
• The sample size is approximately 16,000 students.

22
Sampled Schools
Sampled Schools
School districts with School Dental Prevention
Program
School districts without School Dental Prevention
Program
School district boundaries
23
Module 3

• Supplies and Organization

24
Screening Supplies

• Gloves
• Flashlights and batteries
• Hand Sanitizer
• Cotton Swabs
• Tongue Depressors
• Forms
• Incentives

25
Roles and Responsibilities

• Screeners Will do screenings and fill out forms.
• Teachers Will facilitate screenings by
  collecting consent forms, maintaining order among
  kids and making sure each kid has the right
  results form.
• School nurses Will assist teachers and screeners
  when possible.
• DHEC staff will provide training, supplies, and
  data management capability will conduct some
  screenings.

26
Forms to fill out

• Screening Form
• Results Form
• Screening Checklist

27
Screening Form
28
Results Form
Oral Health Screening Results Location
Date of Screening Childs
Name Thank you for allowing your child to
participate in the Oral Health Needs Assessment
dental screening. The findings from your childs
screening are provided below __________ Needs
regular dental visits __________ Dental
treatment required within a month __________
Dental treatment necessary immediately __________
Your child did not receive a screening
today Please consult with your family dentist.
Your childs health is important to us. If you do
not have a family dentist, please call the Care
Line 1-800-868-0404 and ask for the names and
telephone numbers of dentists in your area. On
behalf of the South Carolina DHEC-Division of
Oral Health, Thank you.
29
Screening Checklist
____ Check in with school principal and give
him/her a coffee mug, CD, and did you know
slip. ____ Check in with school nurse and give
him/her a first aid kit and did you know slip.
If there is no school nurse, give the first aid
kit to the principal. ____ Check your flashlight
batteries ____ Make sure your screening forms
and results forms are ready. ____ When teacher
comes in with class, make sure she knows the
screening protocol, and give her a packet of
tooth boxes and did you know slip. ____ Do
screenings dont forget to check positive
consent on each child! ____ After each child is
screened, give him or her a toothbrush, a
sticker, and a hand stamp. If there is no consent
or negative consent, still give the child
toothbrush, sticker, and hand stamp. ____ At the
end of each classroom, give the stack of results
forms to the teacher. ____ Clean up your
workspace and remember to let the
principal/school nurse youre leaving. Thank them
for their time and participation. ____ At the
end of the day (not after each teacher), seal
screening forms and consent forms for shipping to
DHEC. Include this form on the top of the stack.
30
Module 4

• Administrative Procedures

31
Consent Forms

• IRB Approval
• Superintendent Consent
• Principal Consent
• Parent Consent

32
Parent Consent

• Positive consent the parent signs and says,
  yes, my child may participate.
• Passive consent there is no form to sign, and
  parents are assumed to allow participation unless
  they state otherwise
• Negative consent the parent signs and says, no,
  my child may not participate.

We REQUIRE a POSITIVE consent for this project. A
student cannot be screened without a positive
consent form.
33
Class Lists

• Preferably in Excel format
• Obtained at beginning of school year by programs
  or by DHEC
• Saves time, money, and errors!
• No rewriting/misspelling of names
• Eliminates sloppy handwriting issue
• Faster to do each screening

34
Class List Information
From the school Last Name
First Name
Date of Birth
Grade Level During Screening Gender
Race
Ethnicity
Screening Results From ORS (later)
Medicaid
Free/Reduced Lunch
35
Incentives

• Superintendents
• Principals
• School Nurses
• Teachers
• Participants
• School Dental Programs/ Screeners

36
Distributing Incentives

• Each Program has a box of incentives for each
  school. The box contains
• 1 package for the principal
• 1 package for the school nurse (if there is no
  school nurse, leave this package with the
  principal to include with the schools first aid
  supplies)
• The appropriate number of teacher and student
  packages

Note ALL CHILDREN will receive incentives,
whether they participate in the screening or not.
37
Distribution of incentives to district
superintendents

• Each program will receive a separate box
  containing packaged, labeled incentives for the
  district superintendents in their area. Please
  hand-deliver these gifts to the superintendents
  to increase their awareness of your involvement
  in their district.

38
Data Management Protocol

• Positive consent is required
• Forms will be sealed and delivered to DHEC
• At DHEC, identifiers (names) will be stripped and
  each participant assigned a unique ID number as
  data is entered in computer
• Cross-reference of ID number and name kept in
  locked location separate from database
• All analysis performed on de-identified,
  aggregate data only

39
Followup of participants needing treatment

• Followup will be up to SDPP or school nurses,
  not DHEC staff.
• DHEC cannot provide list of students who need
  treatment to school nurse.
• Day of screening, either SDPP or school nurse
  will handle distributing results forms to
  teachers/students to send home to parents.

40
Module 5 Doing a screening
41
Use Universal Precautions

• Screenings are hands-off
• Make kids pull own cheeks out
• Cotton tip applicator, no instruments

42
South Carolina Protocol

• Always wear gloves
• Change gloves between each child, even if you
  dont touch the child
• If you do not touch the child
• no need to wash hands
• If you do touch the child
• wash hands or use antiseptic rinse

43
Lighting

• Do not rely on natural light
• Use portable dental light, a headlamp or a strong
  penlight/flashlight
• always carry extra batteries

44
Retraction Visualization

• Avoid using fingers
• Have child retract own cheeks, tongue
• Use tongue blade to retract if necessary
• Try to avoid can stick or tear skin
• Use cotton swab to clean surface of tooth if
  required, or wooden end to displace debris

45
No Instrumentation

• Dental explorers will NOT be used.

46
Screening positions for children
47
Screening Positions for children
48
Module 6 Screening Checklist
49
Screening Protocol

• Arrive at site 30 minutes early
• Check-in at school office
• Distribute incentives to principal, nurse
• Find out about recess/lunch
• Set up screening site equipment

50
Screening Protocol

• Check for positive consent
• Review demographic information and fill in
  missing items (if possible)
• date of birth, gender, race/ethnicity

51
Recording Results

• Recorder will circle appropriate answer on
  screening form
• Will record appropriate category on results form
• Give results forms to teachers
• Give screening forms and consent forms to DHEC

52
Screening Protocol

• Teacher walks into screening room with class OR
  screener and recorder enter room (depending on
  whos switching rooms).
• Teacher gives consent forms (in alphabetical
  order!) to recorder
• Teacher maintains order while screening is going
  on.
• Recorder calls first kid forward (reads name off
  screening form)
• Recorder checks consent form. If no consent or
  negative consent, skip to step 9.
• Kid opens mouth
• Screener answers questions
• Recorder records
• Teacher, nurse, or classroom volunteer gives kid
  stamp, toothbrush, and sticker
• After all kids screened, recorder gives results
  forms to teacher and keeps screening forms and
  consent forms
• After all classrooms completed, recorder packages
  and seals screening forms and consent forms for
  delivery to DHEC.

53
Screening Protocol

• Complete direct observation portion of screening
• Enter results on oral health screening form
• Complete referral letter
• Give incentives
• Straighten room and remove garbage
• Thank staff

54
Module 7 What you are looking for and why
55
Rule of Thumb
When in doubt, be conservative. That means that
if you are not sure if a cavity is present,
assume it is not. The BSS is only intended to be
an estimate, not an actual count of specific
needs.
56
Untreated Cavities

• A measure of untreated disease
• Does this child have any cavities that have not
  been treated?
• include both primary permanent teeth
• Cavitated lesions only stains dont count!

57
Definition of Untreated Decay

• A cavity (cavitated lesion) is detected when a
  screener can readily observe two things
• A loss of at 1/2 mm of tooth structure at the
  enamel surface and
• Brown or dark-brown coloration of the walls of
  the cavity

58
Decayed Teeth?

• Retained roots decay
• Broken or chipped teeth are considered sound
  unless decay is also present
• Temporary fillings are considered to be filled
  rather than decayed

59
Caries Experience

• Has this child EVER had a cavity?
• Includes
• untreated decay
• amalgam and/or composite fillings
• temporary restorations
• crowns
• teeth missing because of decay

60
Caries Experience

• Coding

Note caries experience includes restorations!
61
NOTE!!

• Untreated Decay Caries Experience
• If untreated cavities 1 then caries experience
  must 1

62
Treatment Urgency

• Code 0
• no obvious problem
• decay only on primary teeth about to be
  exfoliated
• child can have decayed teeth but not need
  treatment
• routine dental care at next scheduled visit

63
Treatment Urgency

• Code 1
• early dental care needed
• caries detected (cavitated lesion)
• no pain or infection
• precavitated lesion detected
• needs intervention (sealants!)
• dental care within next several weeks

64
Treatment Urgency

• Code 2
• urgent need for dental care
• signs and symptoms include pain, infection or
  swelling or conditions that could reasonably be
  expected to cause pain
• Remember to ask kids about where pain is it
  could be a new tooth!
• needs dental care within days

65
Dental Sealants

• On permanent molars
• Can use cotton swab to lightly feel occlusal
  surface
• Be aware of composites!!

66
Module 8

• Examples

67
Healthy Molars
68
Dental Fluorosis
69
Untreated Dental Decay
70
Early Childhood Caries
71
Retained Root Tips
Retained Root Tip
72
Glass Ionomer Filling on Primary Teeth
73
Amalgam vs Composite
SAME INDIVIDUAL
74
Code 0
75
Code 1
76
Code 2
77
Dental Sealants
78
Dental Sealants
79
Common problems encountered

• Hard to see sealants
• Food or other debris on teeth
• Uncooperative kids

80
Removing Food Debris

• Swish with water
• Long handled cotton swab

81
Early Childhood Caries
82
Code 0
Early Childhood Caries
83
Code 0
84
Code 0
85
Code 0
86
Code 1
87
Code 1
88
Code 2
Fistula from abscessed tooth
89
Code 2
90
What code is this?
91
What code is this?
92
What code is this?
93
What code is this?
94
What is the treatment urgency?
95
Module 10

• Test

96
Exam Procedure

• You will be given an answer key.
• The number of the question corresponds to the
  slide number.
• Fill out each row as though you were screening
  the child whose teeth are shown.
• You must score 80 or higher to participate in
  the OHNA as a screener.