Building School Nurses’ Capacity to Undertake School Dental Screening: A Pilot Project in Santa Rosa, California

ABSTRACT

Background

California school nurses have cited a lack of training as an obstacle to conducting dental screenings. The objectives of this pilot project were to develop educational materials, train school nurses to perform basic dental screening examinations, and evaluate the acceptability and perceived effectiveness of the training program.

Methods

A two-part training program (synchronous webinar followed by practical session) to train school nurses from Santa Rosa City Schools, California, for conducting basic screening surveys was developed during the COVID-19 pandemic. This was a mixed methods study.

Results

At baseline, half of the nurses did not feel confident in performing dental screening (10-point Likert scale scores ranged from 2 to 4). After the training, the nurses reported enjoying the training program as well as an improvement in their knowledge and increase in confidence to 1) screen children’s mouths, 2) identify decayed teeth that need treatment, 3) triage oral health care needs appropriately, and 4) refer children to a dentist (average Likert scale scores of 7–8).

Conclusions

The training program was acceptable to school nurses and increased their perceived capacity to perform school dental screening. This study shows that by training and educating school nurses, it is possible to build their capacity up to the point where they are empowered to confidently perform basic dental screenings.

Practical Implications

School-based dental programs should consider partnering with school nurses to screen for children with dental needs. This study adds to the literature on inter-sectoral collaborations and team-based partnerships to improve oral health.

KEYWORDS:

• School dental screening
• school nurses
• training
• oral health
• dental referrals
• dental caries
• intersectoral collaboration

Introduction

In California, dental caries is the most prevalent chronic childhood disease^1,2 affecting 61% of third graders in 2018–2019.² 7% of Californian school children aged 5–17 years old had missed at least one day of school in the past school year (in 2007) due to a dental problem amounting to a total of 874,000 missed school days.³ In Sonoma County, California, where this project was undertaken, a survey in 2019 found that 41% of the kindergarten and third grade children had experienced dental decay and 16% had not been untreated.⁴ It is possible that the situation may have deteriorated during the COVID-19 pandemic because of the decrease in prevalence of dental visits among U.S. children from 2019 to 2020,⁵ compounded by a decline in schools providing dental screenings and services due to the pandemic.⁶

The California Department of Public Health’s California Oral Health Plan 2018–2028 has (i) identified schools as “targeted sites” to “expand community-clinical linkage programs”⁷ and (ii) listed the expansion of school dental screening programs as one of the key strategies to improve the oral health of Californian children.⁷ Therefore, undertaking school dental screening programs in targeted schools in California is expected to reach a high proportion of children with unmet dental needs.^7,8

In Sonoma County, elementary school nurses are expected to capitalize on the mandated vision, hearing, and learning disability screenings (for transitional kindergarten/kindergarten, grades 2 and 5) as opportunities to do dental screenings. However, the Sonoma County Department of Health Services had received consistent feedback from elementary school nurses, over the past six years, that most nurses skipped the dental screening examinations while still performing the health screenings because “they did not know what they were looking for, and either lacked time or knowledge to do a good job” (written communication, Andrea Pickett, Sonoma County Department of Health Services). This observation is supported by a 2019 survey of school nurses from the California School Nurse Organization that found only 59% of the school nurses performed dental screenings, even though 97% of respondents believed that they could play a role in preventing and reducing dental decay in children.⁹ In that survey, a lack of training or education was cited by 68% of school nurses as an obstacle to them conducting dental screening.⁹ In the peer-reviewed literature, there are very few descriptions on how to train and evaluate school nurses to perform dental screening¹⁰ compared to the amount of materials that have been created by state/local health departments or organizations as training materials for nurses.^11–13

School dental screening is a form of mass screening that takes place in a school setting, where children’s mouths are visually inspected to identify children with oral health needs. School dental screening “can effectively identify students at risk for oral disease and meets students and families where they are in a familiar setting.”¹⁴ The purpose of screening is to identify early evidence of disease previously undiagnosed in apparently well persons.¹⁵ This is followed by notifying their parents/caregivers of the child’s oral health status and treatment needs such that the parents/caregivers are prompted to seek out a dental facility where the child can receive and complete treatment.^16–20 The aim of school dental screening is to detect children with previously undiagnosed dental disease(s) at an earlier, rather than later, stage when the required dental intervention is likely to be more conservative and therefore less complex and costly.²¹ Ideally, school dental screening should identify non-regular dental attendees¹⁹ and stimulate dental visits among those with treatment needs,^20,22,23 thereby leading to improved oral health²⁴ and reduced morbidity.^17,18

Limited evidence supports school dental screenings to improve oral health outcomes in international studies.^{16–20,25,26} In particular, two recent systematic reviews on school dental screening concluded that “there is currently no evidence to support or refute the clinical benefits or harms of dental screening”²⁶ and there is “insufficient evidence to conclude” whether school dental screening ultimately improves dental attendance or not¹⁶ (one of the objectives of school dental screening.^20,22,23 This does not necessarily mean that school dental screening should not be conducted at all because there is “a lot of uncertainty due to the quality of (current) evidence.”²⁶ Moreover, there are a handful of international school dental screening programs that appear to improve oral health outcomes.^22,24,27 In addition, there are at least two U.S.-based studies that have utilized school nurses to perform dental screenings by successfully identifying dental caries.^28,29 In California, about 7,000 children were identified and referred for urgent care in 2008 and 2009 via the California Children’s Dental Disease Prevention Program’s (CCDDPP) school dental screening program, and it is thought that these children would not otherwise have been identified had they not been enrolled in CCDDPP.⁸

Santa Rosa City Schools, the largest school district within Sonoma County serving over 16,000 children in 25 schools, was selected for this pilot project because more than 70% of children in this school district are on the free and reduced-price lunch program (FRLP), which is a proxy measure for students from low-income families.³⁰ The implication is that a high proportion of students at Santa Rosa City Schools are presumably at high risk of caries because disparities exist amongst Californian children by socioeconomic disadvantage for decay experience and untreated decay.² Moreover, in Sonoma County there is a direct correlation in decay experience in kindergarten and third grade children with proportion of children in schools enrolled in the FRLP.⁴

This pilot project involved the development and delivery of an education program to train school nurses to undertake dental screening as part of their overall health screenings. The objectives of this study were to (i) assess the school nurses’ baseline knowledge and prior experience, if any, with dental screening examinations, (ii) tailor the education materials and training program to meet the needs of the school nurses and deliver the training, and (iii) evaluate the acceptability and perceived effectiveness of the training with respect to the improvement in knowledge and increase in self-confidence to: (a) screen children’s mouths, (b) identify a decayed tooth that needs treatment, (c) triage the oral health care needs appropriately, and (d) refer the children with oral health needs to a dentist.

Methods

Participants

This was a mixed methods study that used quantitative (i.e., surveys) and qualitative (i.e., focus groups) methods. All of the school nurses (N = 8) from Santa Rosa City Schools were involved in this project. Since this was an evaluation of a training program, which is not considered “human subjects research,” no IRB submission was required by the University of California San Francisco (UCSF).

Baseline Survey

An anonymous online survey using SurveyMonkey was undertaken in October 2021 to assess the school nurses’ baseline dental knowledge and prior experience, if any, with dental screening. The survey was piloted on two school nurses from another school district in Sonoma County who had experience with performing dental screenings, before distributing to the school nurses involved in the project.

The survey questions (see Appendix Table A1 for the list of questions) included but were not limited to: (i) assessing the school nurses’ current dental knowledge; (ii) for the nurses who had conducted dental screening previously - to assess their (a) experience with dental screening, (b) comfort level in conducting screenings, (c) challenges faced during previous screenings, and (d) process of notifying parents and referring the children to a dentist; (iii) for the nurses who had no prior experience to assess their baseline comfort level to start dental screenings and the reasons why they might be uncomfortable doing or hesitate to perform dental screenings; and (iv) understanding the topics they would like to cover in the education materials. The results of the initial baseline survey were analyzed to inform the appropriate scope and content of the education materials and format of training.

Training

A two-part training program was adapted from the Association of State and Territorial Dental Directors’ (ASTDD) materials for conducting basic screening surveys^31–33 and modified to suit non-dental health care professionals who were assumed to have minimal prior knowledge of oral diseases. Owing to restrictions in group gatherings during the COVID-19 pandemic, the first part of the training (held in mid-November 2021) was a synchronous webinar held virtually over Zoom, where the participants also had the opportunity to ask questions related to oral health and conducting school dental screenings.

The educational topics covered in the webinar were as follows: (i) why oral health is important; (ii) what a healthy mouth should look like; (iii) what to look for in a basic dental screening that is different from a healthy mouth; (iv) how to do a dental screening; (iv) how to do a simple description of the dental findings; and (v) triaging a child’s oral health needs. Immediately following the virtual training session, a second anonymous online survey was conducted using SurveyMonkey to assess: (i) if there were any changes in knowledge and confidence, and (ii) feedback on the webinar (see Table A2 in the Appendix for the list of survey questions). The results of the second survey were analyzed to inform the appropriate scope and content of the next part of the training program.

The second part of the training consisted of a practical session, held in mid-December 2021, where the nurses had the hands-on opportunity to carry out school dental screening on students with a dentist (GC) providing one-on-one coaching. The dentist demonstrated how to perform the dental screening, followed by providing feedback on the nurses’ techniques and posture when they conducted the screenings. The content of the hands-on session covered the following: (i) the preparation and set-up of the nurses’ workstation; (ii) the proper positioning of the nurse and child for dental screening; (iii) steps to undertake dental screenings (for instance, asking the relevant oral health screening questions and correct use of penlight to illuminate the oral cavity); (iv) triaging a child into the correct category of oral health needs; and (v) recording the findings.

Approval was granted by the school district to allow the school nurses to conduct dental screenings on children in transitional kindergarten/kindergarten and grade 2 (where the average ages were around 4 or 5 and 7 or 8 years old, respectively), within restrictions in their respective schools to reduce risk of the spread of COVID-19, such as conducting screening in open air hallways and wearing PPE (such as masks, face shields/eye goggles, and gloves). Written consent from the parents was obtained by the school nurses.

Post-Screening Focus Group

A focus group was conducted over Zoom in early March 2022 to solicit (i) feedback on which aspects of the two-part training was most helpful and could be improved; (ii) the nurses’ experiences with conducting school dental screening including the positive experiences and challenges they faced in (a) conducting the screening, (b) notifying the parent/caregiver, and (c) ensuring the child sees a dentist; (iii) additional support to overcome the challenges highlighted; and (iv) the pros and cons of school nurses doing dental screening during the COVID-19 pandemic. (See Table A3 for the list of focus group questions) Written consent was obtained from the focus group participants prior to participation. The focus groups were first audio-recorded and then transcribed and the participants’ identity were anonymized in the transcript.

Results

Demographics of School Nurses

A total of seven out of eight school nurses responded to the demographic survey with regards to how long they had been a school nurse, their years of experience conducting dental screening, and experience doing oral health-related activities outside of the school setting (see Table 1). Note: Gender neutral pronouns are used throughout the paper to protect anonymity as there was only one male school nurse in Santa Rosa City Schools.

Table 1. Demographics of school nurses in Santa Rosa City schools (n = 7).

Demographics of school nurses	Results	Comments
Years of experience as a school nurse	1 to 3 years: 2 nurses 5 to 6 years: 2 nurses 9 years: 2 nurses 12 years: 1 nurse
Years of experience with school dental screening prior to this pilot program	No prior experience: 2 nurses Under 1 year: 1 nurse 4 to 5 years: 1 nurse 7 to 10 years: 2 nurses More than 10 years: 1 nurse
Experience doing oral health-related activities outside of the school setting	5 nurses did not have experience. Of the remaining two nurses, one was a dental assistant for 2 years before becoming a school nurse, and another one had done “quite a bit of research on oral health in school children” as part of their master’s degree in nursing.	Comparatively, all the seven nurses performed other forms of screening, such as vision and/or hearing.

Baseline Survey

A total of six school nurses completed the baseline survey. The school nurses had a good baseline knowledge of dental caries. For instance, they knew that dental caries was the most prevalent disease amongst California children, that dental caries was preventable, and accurately identified the multi-factorial causes of caries. All six responded that they routinely asked oral health questions as part of their health screening questions even though this was not required of them. One nurse said that they had not previously done school dental screening. Five nurses had previously conducted school dental screening because they thought oral health was important and it were part of their job as a school nurse. Four of them said that they would sometimes or usually encounter a child who required a dental referral.

With respect to their level of comfort/confidence in performing dental screenings, four out of the five nurses were not confident (Likert scale scores ranging from 2 to 4 out of 10), and the remaining nurse felt extremely confident (Likert scale score of 10). The most common challenges faced with past dental screenings were: (i) not knowing how to triage the children into the appropriate level of oral care needs, (ii) not knowing whether the tooth was decayed or not, (iii) finding it difficult to visualize the teeth properly, and (iv) not knowing how to refer the child to a dentist.

Post-Webinar Survey

A total of six school nurses attended the webinar, and the remaining two who could not attend the webinar were provided with the recording of the webinar. Five of the six nurses responded to the post-webinar survey. All five respondents reported that the format worked for them, and the training met their needs. Most of the respondents reported that the webinar had significantly helped them to accurately (i) identify a healthy mouth, (ii) identify a decayed tooth that needs treatment, (iii) triage a child’s oral health needs, and (iv) to perform a dental screening. As a result, they became more confident in carrying out these tasks (see Table 2). The most common concerns or barriers to performing a dental screening that the participants still had despite attending the webinar were: (i) difficulty in visualizing the teeth properly and (ii) not knowing how to triage a child’s oral health needs.

Table 2. Nurses’ self-perceived change in knowledge and confidence in conducting school dental screening after attending the webinar (n = 5).

Change in nurses’ self-perceived knowledge after attending the webinar [Options: (a) Yes – significantly; (b) Yes – marginally; (c) No change at all; (d) No it doesn’t help me; (e) I don’t know]
Questions	Yes – significantly	Yes – marginally	No change at all
Did the training help you to accurately identify a healthy mouth, if at all?	4	1	0
Did the training help you to accurately identify a decayed tooth that needs treatment, if at all?	3	2	0
Did the training help you to accurately triage a child’s oral health needs, if at all?	3	1	1
Did the training help you to accurately perform a dental screening?	4	1	0
Nurses’ self-perceived confidence to perform the following tasks after attending the webinar* [Likert scale: where 0 is extremely unprepared, 5 is neutral, and 10 is extremely confident]
Questions	Average score (range of scores)
After attending the training, how confident are you in identifying a healthy mouth?	8 (6–9)
After attending the training, how confident are you in identifying a decayed tooth that needs treatment?	7 (6–10)
After attending the training, how confident are you in triaging a child’s oral health needs?	8 (6–10)
After attending the training, how confident are you to perform a dental screening?	8 (6–9)

*Comparatively, at baseline, four out of the five nurses were not confident (Likert scale scores ranging from 2 to 4) and the remaining one felt extremely confident (Likert scale score of 10).

Practical Session

Seven school nurses attended the practical session. A total of 120 school children (transitional kindergarten/kindergarten to grades 2) across six elementary schools were screened over a week. Of the 120 children who received a dental screening, none required emergency care, 10 required urgent dental care (8.33%, all due to extensive decay), 22 required early dental care (18.33%, all due to decay), and 88 had no obvious dental problems detected (73.33%).

Some aspects the nurses found challenging and consequently became the training focus were as follows: (i) the correct use of the disposable mouth mirror and penlight, (ii) the proper positioning of the nurse during the screening, (iii) distinguishing between healthy and unhealthy teeth (in particular distinguishing stained fissures and/or hypomineralized areas of the teeth where the dentine was visible from dental caries), and (iv) triaging a child into the correct category of oral health needs especially with regards to the nuances between the categories of “requiring urgent care” versus “requiring early care.”

Post-Screening Focus Group

All the school nurses attended the focus group. In describing their school populations generally, all the nurses reported that the prevalence of dental caries was quite high. One nurse described it as: “I would say at my elementary [school] level, the oral health is probably not the greatest … A lot of pain issues, and just seems a lot of cavities, a lot of fillings … I would say annually when I screen, probably 20 of the 90 maybe are reporting pain … I’m sending quite a few dental referrals home.”

General Feedback on the Training

All the nurses found the training helpful with respect to “what we were going to do, what we were looking at” during the dental screening examinations. With respect to learning how to differentiate between the different levels of oral care that required a referral, the nurse who was a dental assistant previously with more than a decade of experience with dental screening stated that “I was thinking that seeing the holes in the teeth, that would be an immediate referral. But it was interesting to learn that we’re looking at really more than just one cavity or just more than one tiny hole. We’re looking at urgent cases, looking at more cavities, and looking at really, having pain, discomfort, you know that being more of an urgency and emergency. Learning the difference between urgent versus emergency was really helpful.”

Feedback on the Webinar

The photos of decayed teeth were commonly cited as the most helpful part of the webinar. At least half of the nurses said they had/would laminate the pictures to use as a reference during future screenings. No aspect of the webinar was identified as unhelpful, though one nurse would have preferred an in-person seminar (note: at that time, there were COVID-19 restrictions with respect to group gatherings).

Feedback on the Practical Session

For the aspects of the practical session that the nurses found helpful, one nurse explained that “it was learning little techniques of clearing the mirror when it fogs to be able to see, using your pen light, using the mirror and reflecting the light, and being able to see the tooth better that way.” Another nurse found “alternating between observing and showing” useful – to first observe a dentist (GC) perform screening on the first few children, followed by having the opportunity to practice with a dentist observing them and offering “more tips” and “showing a new tip on another student,” followed by having the opportunity to practice on more students again.

With regards to which aspects of the practical session that could be improved, one nurse found it challenging to perform screenings on transitional kindergarten children (ages 4–5 years old) because some of them were “scared and not opening their mouths properly” and said that “it would have been better [for their learning] if they had started with older children.” Another nurse who also screened transitional kindergarten students found that by the dentist “doing a [dental screening] demonstration in front of the children so they knew what to expect, was very helpful” in terms of allaying the anxieties that younger children may have with respect to undergoing dental screenings.

Challenges with Notifying Parents After the Dental Screening Examinations

All the nurses said that they had experienced challenges in trying to notify parents of the screening findings, and in following-up to ensure that the children had been seen by a dentist. Unless the parents informed them that they had brought the child to see a dentist, or they re-screened the child, the nurses would not know whether the child had seen a dentist or not. In the words of one nurse: “It’s hard because when we fill out a referral form, I find that some schools will mail them for us but that is few and far between. A lot of times, we’ll put them in an envelope and then it’s like ‘Did it even get to the [child’s] house?’ ‘Did it get in their backpack?’ ‘Once it got in their backpack did the parents even see it?’ … If it’s something that we’re super concerned about, then we either pull in family engagement or we follow up ourselves. But that takes so much time, and a lot of us, most of us, have like three or four schools that we’re covering … so the amount of time that we have dedicated to that [following up with parents] is low, very, very low.”

Suggestions for Support to Overcome the Highlighted Challenges

In response to suggestions for overcoming challenges faced in notifying parents and following-up with parents to ensure that the children see the dentist, the nurses opined that having external help (such as family engagement) to reach out to the parents and connect the children to the dentist would help. This was to overcome issues such as (i) the time and bandwidth constraints that the nurses faced with following up with multiple families especially during the busier times of the school calendar; (ii) language barriers between nurse(s) and families; and (iii) access issues that the children or family may face such as transportation to the clinic from rural areas, and parents having to take time off work to bring the children to the dentist. In terms of additional support that nurses should receive for conducting dental screenings, the nurses opined that they would like (i) their schools to support the resources to purchase the equipment for dental screenings; (ii) to receive annual refresher trainings, and (iii) knowing which were the dental clinics in the community that accepted Medi-Cal dental patients and treated special needs children such that this information could be attached with the referral note to the parents.

Discussion

After attending the training program, most of the nurses reported a significant improvement in their knowledge and confidence level to perform dental screening (in particular to examine, identify decayed teeth that needs treatment, triage a child’s oral healthcare needs, and refer children to a dentist); compared to the baseline where half of the nurses were not confident to performing dental screenings. The nurses also highlighted two important things they learned: (i) that not every “visually detected discoloration” needed referral, and (ii) there was a distinction between children who required “urgent” versus “early” care. These learning points were important because during the webinar some nurses shared that they were concerned about “over-referring” cases to the dentist. As such, the two-stepped pilot training achieved its intended aim of building capacity and empowering school nurses to undertake school dental screening. The pilot training program was different from the other training programs for school nurses^10–13 in that (i) the training program was tailored to the nurses’ needs and (ii) the training was conducted by a dentist and that the practical training also included a one-on-one coaching.

Following the screening examinations, the nurses also faced challenges that were related to notifying parents and following up with parents to ensure that the children received treatment. Addressing these challenges are equally as important as training the nurses to confidently and accurately undertake dental screening examinations because school dental screening works to improve population health only when the screened positive children attend for and complete appropriate treatment for the screened conditions.^18–20,27 School dental screening is a multi-stepped, complex process,¹⁷ and the screening examination is only one step. When one or more of the screening steps (i.e., identification, notification, dental attendance, and/or completion of treatment) are ineffective, the overall effectiveness of the school dental screening program diminishes.¹⁷ Similarly, the school nurses also highlighted other challenges such as linguistic barriers in notifying the parents, the socioeconomic situation of the child’s family and access to dental care that may impact the families’ ability to follow-up and seek care. These issues have also been highlighted in the literature as some of the explanations for the generally low uptake of dental treatment following screening.^17,22,26 As such, it is essential that the planners of any school dental screening program need to address all the steps in the screening process to ensure its overall effectiveness.

Implications for Dental Public Health

This study revisits the concept of a team-based approach to holistically improve oral health by leveraging non-dental healthcare professionals, in particular school nurses,^33–35 as partners to reach at-risk families in setting(s) familiar to them with an organization they trust (i.e., the school).¹⁴ For instance, the 2014 Health Resources and Services Administration’s report on integrating oral health in primary care practice calls for interprofessional strategies that include, utilizing school nurses to provide oral health hygiene education, conduct basic oral health screening for public health surveillance, triage dental emergencies and refer children for dental visits.³⁶ At least two recent U.S.-based studies have successfully utilized school nurses to conduct dental screenings to support this public health recommendation.^28,29

Tapping on school nurses as an important resource is needful because even before the COVID-19 pandemic, dental care in the U.S. among disadvantaged communities was already utilized to a lesser extent than primary medical care,¹⁴ and the pandemic amplified the disparities in dental access.⁵ Incorporating dental care into schools has been proposed as one of the means to augment the dental safety net and catch those who have fallen through the holes in the safety net.³⁷ In the context of schools, school nurses are the health care professionals trusted by the children, parents, teachers and administrators; have established personal rapport with students and parents; provide culturally competent care; and are therefore “in the perfect position to fill the role of oral health champions.”^34,37 Finally, it has been argued that school nurses working in areas that are rural, lower socio-economic status, and/or designated as Dental Health Professional Shortage Areas can “bridge access to dental care gaps in their communities” and reduce the effects of oral health disparities.³⁴

Strengths and Limitations

This study adds to the literature on inter-sectoral collaboration and partnership with non-dental health professionals to perform dental screening, in particular describing the planning and conduct of a training program. Some limitations of this project are the small sample size which limits generalizability and breadth of findings, and that information about nurses’ ability to perform dental screenings were all self-reported which is important for confidence but lacks an assessment of accuracy.

Additional limitations of this pilot project can be attributed to the COVID-19 pandemic. Following the practical session in December 2021, the nurses were unable to perform any further routine dental screenings except on children who specifically complained of dental pain, because of the spike in Omicron-variant cases and the school district’s regulations for the students to always keep their masks on during the ongoing pandemic. This meant that the authors were unable to evaluate the accuracy or effectiveness of the nurses’ with doing school dental screening or even conduct another practical training session for calibration (as was originally planned). The lack of opportunity to perform additional screenings may also have eroded some of the nurses’ confidence gained after completing the training program.

Conclusions

This pilot program was acceptable to the school nurses, and this study shows that by training and educating school nurses, it is possible to build their capacity up to the point where they are empowered to confidently perform basic dental screenings. School-based dental programs should therefore consider partnering with school nurses to screen for children with dental needs. Following the dental screening examinations, additional support in notifying the parents and following-up is needed to ensure that dental treatment is completed.

Acknowledgments

The authors are grateful to all the school nurses from Santa Rosa City Schools who participated in this study (Jennifer Rodriguez, Alison O’Herlihy, Nicholo Atup, Heather Ginnever, Sangmo Witzman, Amanda Arend, and Cheryl Closser) as well as to Terese Voge (Sonoma County Department of Health Services) for her advice and support for this project.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

Other than funding from the Sonoma County Department of Health Services to procure the personal protective equipment and dental mouth mirrors for conducting the practical teaching session, no other sources of financial support were received for the conduct for this study.

Notes on contributors

Gabriel Tse Feng Chong

Gabriel Tse Feng Chong, BDS, MPH (Hons), MFOdont (Dist), DipFHID, EMBA, FAMS (DPH), MRACDS (DPH), FFFLM, is a Consultant in Dental Public Health and Forensic Dentistry. He is currently serving as an active-duty Dental Officer in the Singapore Armed Forces (SAF) as the Head of General Staff of the SAF HQ Medical Corps. This project was undertaken during his studies at the University of California San Francisco, which was sponsored by the SAF.

Andrea Pickett

Andrea Pickett, MPH is a Health Information Specialist with the Sonoma County Department of Health Services, Public Health Division. She is the Project Coordinator for the Sonoma County Oral Health Program.

Elizabeth Munns

Elizabeth Munns, RN, BSN, PHN, MS is the Head School Nurse at Santa Rosa City Schools. She is registered with the California Board of Registered Nursing.

Kristin Hoeft

Kristin Hoeft, PhD, MPH, is Associate Professor in the Division of Oral Epidemiology and Dental Public Health at the University of California, San Francisco School of Dentistry.

Appendix

Table A1. Survey questions in the initial baseline survey.

S/N	Questions grouped by categories
Assessing the school nurses’ current dental knowledge
1	What is the single most widespread disease amongst children in California? Options: (a) Asthma; (b) Myopia; (c) Obesity; (d) Tooth decay; (e) Trauma; (f) Mental health/behavioral issues; or (g) Others (please list).
2	Make a guess as to what is the percentage of Californian children who have untreated tooth decay by 3rd grade?
3	Tooth decay is caused by the following [You can select one or more of the options] Options: (a) Diet high in sweets; (b) Poor brushing habits, or not brushing at all; (c) Sleeping with a milk bottle or sweetened beverages; (d) Trauma to the face and/or mouth; (e) Lack of water fluoridation in Sonoma County; (f) Poor genes are to blame; (g) Bacteria in the mouth are to blame; (h) Too much fluoride will actually cause decay; (i) I don’t know; and/or (j) Others (please list).
4	Do you agree with the following statement: tooth decay can be prevented. Options: (a) Yes; (b) No.
5	Which of the following do you believe to be true concerning baby teeth? [Tick all the options that apply to you] Options: (a) The child may be in pain and miss school; (b) Healthy children should have good oral health; (c) I have read or heard about stories where some children have all their teeth pulled out because of decay or infection; (d) Poor oral health can lead to infections in other parts of the body because the decayed teeth can harbor bacteria; (e) Poor teeth can affect nutrition; (f) Poor teeth can affect the child’s self-esteem; (g) Poor teeth can affect the child’s speech; (h) Some children have been in dental pain for so long that they think it is normal; (i) That’s not my job as a school nurse. It’s the dentist’s job to look after teeth; (j) Why bother, they are going to fall out anyway; (k) It is just teeth, no major problems will arise with decay; and/or (l) Others (please list).
Finding out the school nurses’ experience and/or opinion regarding dental screening
6	Is asking oral health questions a mandated part of your health screenings for students? Options: (a) Yes; (b) No.
7	Do you routinely ask oral health questions as part of your mandated questions? Options: (a) Yes; (b) No.
8	Have you ever conducted dental screening as part of your mandated health screenings? Options: (a) Yes, if you have answered ‘yes’ please go to question 9; (b) No, if you have answered ‘no’ please go to question 19.
9	How frequently do you conduct dental screening(s)? [Free text answer]
10	How long did you take, on average, to do a dental screening per child? Options: (a) 0 to 30 seconds; (b) 30 seconds to under 1 minute; (c) 1 to under 2 minutes; (d) 2 to under 5 minutes; (e) 5 to 10 minutes; or (f) More than 10 minutes.
11	How confident are you performing dental screening(s)? [Likert scale: 0 being extremely unprepared, 5 being neutral, and 10 being extremely confident]
12	Why have you done dental screenings in the past? [Select all the options that apply to you] Options: (a) I was examining the student’s mouth anyway and decided to also take a look at the teeth; (b) I was providing a value-added service, in addition to checking the student’s eyes, ears, and mouth; (c) I think oral health is important; (d) This is part of my job as a school nurse; (e) The child told me that he/she was in pain so I had a look; and/or (f) Other reasons (please list).
13	What challenges did find when you did the dental screenings in the past? [Select all the options that apply to you] Options: (a) I didn’t face any challenges; (b) I don’t know whether the tooth is decayed or not; (c) I find it difficult to see the teeth properly; (d) I don’t know how to refer children to see a dentist; (e) I don’t know whether children need dental care urgently, early care, or just routine care; and/or (f) Others (please list).
14	How frequently per year do you refer children who need follow-up dental care? [Likert scale: 0 being never referred a child, and 10 being every time I see a child with tooth decay]
15	How do you refer children who need follow-up dental care? [Free text answer]
16	What difficulties (if any) do you face with referring children who need dental care? [Free text answer]
17	How do you inform the parents/guardians of children that need follow-up dental care? [Free text answer]
18	What difficulties (if any) did you face when informing the parents/guardians of children that need dental care? [Free text answer]
19	How long do you think it will take, on average, to do a dental screening per child? Options: (a) 0 to 30 seconds; (b) 30 seconds to under 1 minute; (c) 1 to under 2 minutes; (d) 2 to under 5 minutes; (e) 5 to 10 minutes; or (f) More than 10 minutes.
20	How comfortable do you think you will be doing dental screening(s)? [Likert scale: 0 being extremely unprepared, 5 being neutral, and 10 being extremely confident]
21	What are some of the reasons why you might be uncomfortable doing a dental screening, or at the very least hesitate about starting a dental screening? [Select all the options that apply to you] Options: (a) I don’t know whether the tooth is decayed or not; (b) I find it difficult to see the teeth properly and I don’t want to miss anything; (c) I find it difficult to see the teeth properly because I have to bend over; (d) I don’t know how to refer children to see a dentist; (e) I don’t know whether children need dental care urgently, early care, or just routine care; and/or (f) Others (please list).
22	If you were provided with training and the right equipment, how comfortable do you think you would be doing dental screening(s)? [Likert scale: 0 being extremely uncomfortable, 5 being neutral, and 10 being extremely comfortable]
Finding out what the school nurses would like to learn in the training, and format of the training
23	Did you attend the last training (held in 2019) on conducting dental screenings that was organized by the Sonoma County Department of Health Services? Options: (a) Yes, if you have answered ‘yes’ please continue with question 24; (b) No, if you have answered ‘no’ please go to question 27.
24	What do you remember from the last training? [Free text answer]
25	What do you think went well with the 2019 training? [Free text answer]
26	What do you think can be improved with the 2019 training? [Free text answer]
27	What kind is the training format that you like going forward? [Select all the options that apply to you] Options: (a) In-person (depending on the prevailing COVID-19 situation); (b) Virtual over Zoom, WebEx, Microsoft Teams, or similar platform; (c) Website with instructions and videos; and/or (d) Hybrid: virtual followed by in-person (if the COVID-19 situation allows).
28	How frequently do you think the training(s) should be held? [Select one option only] Options: (a) At least once every 3 months; (b) At least once every 4 months; (c) At least once every 6 months; (d) At least once every 12 months; (e) At least once every 24 months.
29	What would you like to learn in the next training? [Select all the options that apply to you] Options: (a) Identifying whether a tooth is decayed or not; (b) Identifying whether a tooth has a filling or not; (c) Identifying whether a filling is defective or not; (d) Identifying whether a tooth has a metal filling or decay; (e) Identifying whether the decay is active or has been arrested by fluoride or silver diamine fluoride: (f) Identifying whether there is an active infection or not; (g) Triaging a child into requiring urgent care, early care, or routine care; (h) How to refer a child to a dentist; (i) How to inform the child’s parent that he/she needs follow-up dental care; (j) Coaching on the appropriate questions to ask so as to triage a child into low / medium / high risk of developing tooth decay; (k) How to examine the mouth properly; (l) How to apply fluoride varnish; and/or (m) Others (please list).

Table A2. Survey questions in the post-webinar survey.

S/N	Questions grouped by categories
Assessing change in knowledge and confidence
1	Did the training help you to accurately identify a healthy mouth, if at all? Options: (a) Yes – significantly; (b) Yes – marginally; (c) No change at all; (d) No it doesn’t help me; (e) I don’t know.
2	After attending the training, how confident are you in identifying a healthy mouth? [Likert scale: where 0 is extremely unprepared, 5 is neutral, and 10 is extremely confident]
3	Did the training help you to accurately identify a decayed tooth that needs treatment, if at all? Options: (a) Yes – significantly; (b) Yes – marginally; (c) No change at all; (d) No it doesn’t help me; (e) I don’t know.
4	After attending the training, how confident are you in identifying a decayed tooth that needs treatment? [Likert scale: where 0 is extremely unprepared, 5 is neutral, and 10 is extremely confident]
5	Did the training help you to accurately triage a child’s oral health needs, if at all? Options: (a) Yes – significantly; (b) Yes – marginally; (c) No change at all; (d) No it doesn’t help me; (e) I don’t know.
6	After attending the training, how confident are you in triaging a child’s oral health needs? [Likert scale: where 0 is extremely unprepared, 5 is neutral, and 10 is extremely confident]
7	Did the training help you to accurately perform a dental screening? Options: (a) Yes – significantly; (b) Yes – marginally; (c) No change at all; (d) No it doesn’t help me; (e) I don’t know.
8	After attending the training, how confident are you to perform a dental screening? [Likert scale: where 0 is extremely unprepared, 5 is neutral, and 10 is extremely confident]
9	Are there any other concerns or barriers to performing a dental screening that you still have despite attending the training? [Select all the options that apply to you] Options: (a) I don’t have any concerns or barriers; (b) I don’t know whether the tooth is decayed or not; (c) I find it difficult to see the teeth properly; (d) I don’t know how to refer children to see a dentist; (e) I don’t know whether children need dental care urgently, for early care, or just routine care; and/or (f) Others (please list).
Feedback on the training
10	Did the format work for you? Options: (a) Yes; (b) No.
11	Did the training meet your needs? [Free text answer] If you select ‘yes’, please explain what was met. If you select ‘no’, please explain what was not met.
12	What was good about the training? What could be improved? [Free text answer]
13	Which aspect(s) would you like to concentrate on during the one-on-one training? [Select all the options that apply to you] Options: (a) How to set up for the dental screening; (b) Asking the relevant oral health questions; (c) How to visualize the child’s mouth; (d) Identifying a healthy mouth; (e) Identifying a decayed tooth that needs treatment; (f) Triaging a child’s oral health needs; (g) Describing the child’s oral health needs; and/or (h) Others (please list).

Table A3. Post-screening focus group questions.

S/N	Questions grouped by categories
1	Tell us about the oral health of the students at your school. How does it compare to other health problems students have?
2	What did you think of the two-part training program in general?
3	Which aspects of the webinar were most helpful to you? And why?
4	Which aspects of the webinar could be improved and why?
5	Which aspects of the hands-on practical session were most helpful to you? And why?
6	Which aspects of the hands-on practical session could be improved? And why?
7	Think of the average school nurse, if the average school nurse went through this training program, how confident do you think the average school nurse will be in performing a dental screening?
8	Do you think doing school dental screening improves the health outcomes for children who have oral health needs? Please share a story of something that went well during your hands-on session/doing the screening on your own.
9	What challenges, if any, did you face doing the dental screening during the hands-on session? For example, what challenges did you face in: Positioning yourself, using the mouth mirrors, and pen light; Identifying decayed teeth, Triaging a child into the appropriate care level, Are there any other challenges that anyone faced but we have not yet talked about?
10	Let’s talk about what happens after doing the screening, maybe one person can share about his/her challenges with notifying the parents?
11	What happens if you had referred a child to the dentist but notice that at the following screening session (or after some time), the child has not yet seen a dentist? Can someone share their experiences about following up to make sure that the child has seen the dentist?
12	What additional support do you think nurses should receive to help conduct school dental screenings?
13	I know that school nurses are busy during the COVID-19 pandemic, what do you think of the pros and cons of school nurses across California doing dental screening?
14	Is there anything that you want to give feedback about, or comments about oral health and school nurses in general?