The Pragmatic Research to Implement Sustainable Medicine in Schools (PRISMS) project explores the policy, community, and clinical barriers that inhibit the implementation and reach of innovative school-based dental programs.
Dental caries (tooth decay) is the most prevalent childhood disease in the world, afflicting over 1.2 billion individuals. It is also highly inequitable. Children with untreated caries face severe health consequences and/or psychosocial impairment, including increased risk of systemic infection, pain, and negative effects on academic performance. To increase access to care and prevent caries, the CDC recommends school-based sealant programs (SBSPs) applied by dental hygienists. However, SBSPs are underutilized due to prohibitive costs and professional staffing limitations. Using the CariedAway school-based oral health network: a multi-state collaboration of over 80 schools to provide caries prevention to high-need children, we recently demonstrated that (1) silver diamine fluoride (SDF)—an innovative, non-surgical, WHO-recommended, minimally-invasive therapy for dental caries—is non-inferior to dental sealants in the arrest and prevention of caries when implemented in a school-based oral health program. We also showed that (2) nurses, who are available in many schools, can effectively apply SDF. This phase-2 translational research project demonstrated that school-based dental medicine can expand to include SDF and existing school health personnel.
Despite the positive steps made in evaluating the impact of school-based caries prevention using SDF, critical evidence gaps remain for the implementation and sustainability of these programs. These barriers include structural and policy support, engagement and participation, and care delivery and implementation. PRISMS is a T3 dissemination and implementation (D&I) project consisting of the following objectives:
Assess the existing policy systems that frame, support, or inhibit the implementation of school-based caries prevention programs using SDF.
Identify the capacities needed at the local level to support sustainable, school-based care using SDF and develop a framework to address those capacities. This includes assessing the opportunities and challenges for local implementation and the knowledge, attitudes, and practices of school nurses engaged in care.
Evaluate a nurse/SDF program as part of scalable model for school-based oral medicine. We will employ a stepped-wedge design to implement and assess an evidence-based SDF program in schools utilizing existing school nurse personnel in a large, culturally-diverse patient population.
Our multilevel investigation into sustainable, school-based care will utilize the Consolidated Framework for Implementation Research and the Proctor Model for Implementation Research, and adopts the PRECEED-PROCEED model for program evaluation. Our approach focuses on five key target areas: (1) we explore key assumptions at the system, organizational, group, and individual levels; (2) we directly focus on a critical unmet need in underserved populations; (3) we target children from low-income backgrounds that historically lack representation and voice in traditional dental medicine; (4) our selection of silver diamine fluoride as the primary intervention for school oral health programs is evidence-based; and (5) our primary outcome will include systems and policy descriptions and patient-centered outcomes evaluations.