Emma Nodine

BACKGROUND 

A.1 Dental caries, tooth decay, is the most prevalent chronic disease in children (NIH, 2022).

            Dental caries, commonly known as tooth decay, represents a highly prevalent chronic disease in children (NIH, 2022). Harmful social and biological factors accumulated early in life contribute to the risk of tooth decay in children throughout middle to late childhood (Peres et al., 2005). Untreated dental caries leading to poor long-term oral health significantly compromises overall health in children by inhibiting sleep quality, nutritional intake, behavioral regulation, and daily functioning, leading to downstream educational and behavioral consequences (Drummond et al., 2013; Mouradian et al., 2000). Throughout the world, socioeconomic status (SES), including factors such as family income and parental education status, consistently correlates with higher rates of dental caries, poorer oral-health–related quality of life (OHRQoL), and inadequate preventive oral hygiene behaviors (Almajed et al., 2024; Mouradian et al., 2000). These disparities cause a disproportionate burden among children from socioeconomically disadvantaged backgrounds. 

A.2 Socio-economic inequality makes a disproportionately lasting impact on oral health in children through adulthood.

            Insurance coverage and healthcare utilization patterns throughout the United States highlight the existing equity gap between insurance prevalence, insurance coverage limits, and dental healthcare utilization (Pouraskari et al., 2024). National analyses demonstrate that children at or near the poverty line have substantially lower odds of receiving preventive dental care compared to their peers with higher socio-economic status, even following adjustment for demographic variables including race, ethnicity, age, and sex (Watson et al., 2001). Survey-based studies identify structural barriers involving insurance for low-income and Medicaid-enrolled populations, including reduced sealant usage, an insufficient number of participating dentists, and reimbursement mechanisms that disincentivize preventive care (Dasanayake et al., 2001). While one NHANES analysis indicated similar caries odds by insurance category after controlling for SES, low income itself remains a robust predictor of untreated disease (Duffy et al., 2018). Recent studies examining dental sealants as a targeted form of preventative dental care that is a highly effective treatment to prevent caries reveal gaps in access for children with non-private insurance. The study shows that children with public insurance only, both private and public insurance, and fully uninsured children were all less likely to have received preventative treatments, particularly sealants, than peers with only private insurance. These disparities were more significant in certain demographics, including Black children, children of families below the 200% poverty-level, and children facing socioeconomic or language barriers, indicating inequities in proper preventative dental care exist even in the presence of some insurance (Bahanan, 2024). 

A.3 Impact of Poor Oral Health on Childhood Development and Life-long Consequences. 

            Early childhood caries (ECC) and untreated dental decay impair proper daily functioning, such as core developmental tasks and school participation, and childhood development. Dental pain and infection are often overlooked in young children, but they commonly disturb sleep, reduce appetite, and trigger behavior and attention problems in children that impact developmental behaviors and performance in school (Drummond et al., 2013). Studies examining the influence of dental care on children’s well-being highlight the correlation between ECC in young children and worsened oral health in adolescence and into adulthood, including higher risks of caries, periodontal disease, malocclusion, and the development and worsening of dental anxiety due to long-term avoidance (Drummond et al., 2013). 

            Poor oral health and dental disease also affect growth and nutrition in children. Studies have found that children with severe dental caries often weigh less than their peers due to chronic inflammation affecting metabolic pathways, emphasizing the need to treat dental caries in pre-school children to increase growth rates and improve oral-health–related quality of life (OHRQoL) in children long-term (Sheiham, 2006). As shown in Table 1, a randomized controlled trial found that treating severe dental caries in school-age children improved dental pain, sepsis, appetite, and anthropometric measures, as indicated by “satisfaction” with teeth and smile, reinforcing the link between oral care and overall health (Alkarimi et al., 2012). Population-level policy reviews also connect poor oral health to negative impacts on schooling and costly downstream dental care, with the burden disproportionately concentrated among low-income and minority children (Mouradian et al., 2000). These impacts on schooling occur as poor oral health is associated with more school absences, lower grades, and reduced academic achievement from pain-related absences and inhibited ability to focus, highlighting education costs that concentrate in disadvantaged groups (Jackson et al., 2011). Longitudinal studies show that oral-health disadvantages in early childhood cause impacts that persist into adolescence and adulthood, widening health and OHRQoL gaps (Almajed et al., 2024; Peres et al., 2005). 

A.4 Existing income disparities impact the Charleston peninsula due to a large influx of tourism and high-income in-migration. 

            Since the 2020 Covid-19 pandemic, the Charleston peninsula has attracted a large influx of higher-income residents and is experiencing rapid population growth (Portal, 2025). A combination of large institutions, rapid in-migration of residents, and a tourism surge have significantly changed the income distribution throughout the Charleston area. These large institutions include the Medical University of South Carolina (MUSC), which employs more than 17,000 workers with 3,300 students, and the College of Charleston, which supports a large professional workforce and student economy downtown, concentrating higher-wage jobs on the peninsula (CHSBusiness, 2020; Development, 2024). Alongside a growing increase in high-wage jobs, tourism also surged in the Charleston peninsula, driven by higher per-visitor spending since the 2020 pandemic (Moore, 2025). The significant in-migration of approximately 42 new residents per day, alongside an influx of high-income populations, is causing gentrification within downtown neighborhoods and increasing demand for affordable housing and services in the urban core of the Charleston peninsula for the original residents (Development, 2025). These shifts in residential populations have displaced many long-standing low-income communities from the peninsula, concentrating the remaining low-income communities in certain neighborhoods on the peninsula (Blakeney, 2023). Many low-income families have children who are students served by Title 1 schools, which highlights a need to place preventative services directly on the schools’ campuses, where dental care is accessible, to best close geographic and eligibility gaps. 

A.5 Gaps in Current Resources Available to Children Attending Title 1 Schools in the Charleston Peninsula (Duffy et al., 2018).

            Though there are several supportive dental treatment options throughout Charleston for vulnerable populations, most are unevenly distributed and often treatment-oriented rather than preventive. Several services are located off-peninsula or serve restricted populations, such as East Cooper Community Outreach and North Charleston Dental Outreach. East Cooper Community Outreach (ECCO) runs dental clinics that focus on extractions and is limited to uninsured residents living east of the Cooper River, excluding all children of families living on the peninsula, which is located on the west side of the Cooper River, including those who are underinsured and otherwise eligible (ECCO, 2025). North Charleston Dental Outreach does offer several treatment options involving preventative care, however, the hours are limited to weekdays during working hours, and the location is in North Charleston, which inhibits many children in the peninsula with working parents from receiving the care they need, despite their financial eligibility (NCDO, 2025). While Fetter Health Care Network provides fixed-site and mobile dental services and seasonal school sites, availability is dispersed across locations throughout rural areas surrounding Charleston County, making consistent preventive care difficult for students to access in the peninsula (FetterHealthCareNetwork, 2025). 

            These access barriers in Charleston represent broader national patterns of oral health disparities, in which use of preventive treatments remains low among low-income children, with a focus on treatment of more severe complications once they develop. Medicaid analyses in Alabama highlighted low sealant usage among Medicaid patients and geographic disparities due to regions with no Medicaid-participating dentists (Dasanayake et al., 2001). National surveys show many low-income children miss routine preventive visits and are less likely to receive preventive care such as cleanings, fluoride, and sealants intended to target primary and early secondary prevention (Watson et al., 2001). A 2024 study found that children with public-only, a combination of public/private, or no insurance were less likely than their peers with private insurance to receive sealants. The largest gaps between demographics found were among Black children, families below 200% of the federal poverty level, and those facing language barriers (Bahanan, 2024). Several Title I schools in the Charleston peninsula serve high-need populations children in low-income families, emphasizing the need to deliver preventive oral health services on-site where children in need regularly attend school and are accessible to offer early prevention.

A.6 School-Based Prevention programs have been proven to be effective in reducing caries risk in school-age populations. 

            School-based sealant programs (SBSPs) are one of the most effective and accessible strategies for decreasing caries prevalence in high-risk adolescent populations (Johnson et al., 2017). A 2017 policy modeling study conducted in Georgia demonstrated that SBSPs reached a greater number of children at a lower cost than strategies relying solely on provider fee increases. Additionally, the program enabled dental hygienists to practice under general supervision, instead of costly direct supervision, which reduced program costs by over 50% while expanding reach to the target population (Johnson et al., 2017). Beyond direct clinical prevention, school-based educational oral health programs can result in sustained long-term benefits in perceived oral health and daily functioning extending beyond adolescence and into young adulthood (Alsumait et al., 2015). Reviews on the studies of management of Early Childhood Caries (ECC) further highlight the efficacy of minimally invasive preventative treatments such as sealants, resin infiltration, and silver diamine fluoride (SDF) that preserve tooth structure and help prevent the development of future complications, making these methods highly suitable for school-based delivery programs (Drummond et al., 2013). 

A.7 Overview of Proposed Intervention Program Rationale 

            The concentrated cluster of Title I schools within the Charleston peninsula provides an optimal opportunity for a school-based oral health prevention and navigation program for low-income, underserved students on the Charleston peninsula (Education, 2024). This intervention would involve on-site screenings, fluoride varnish applications, and sealant placement for underserved students at risk for caries and poor oral health development. The program will involve Charleston County School District (CCSD) nurses, MUSC dental school students, and Trident Technical College students. Consent processes and oral health education would be integrated into existing school documentation to allow for parent and guardian consent without requiring their physical presence. The literature suggests that a focus on a specific insurance coverage category may overlook certain high-risk children, so the program will be open to both uninsured and underinsured students (Duffy et al., 2018). The program will integrate both preventative treatments, referrals to MUSC partners for identified oral health complications, and educational programs to equip students with the necessary knowledge to maintain proper oral health long term. Services will be delivered by dental hygiene students of Trident Technical College and dental students of Medical University of South Carolina. 

RESOURCES 

Alkarimi, H. A., Watt, R. G., Pikhart, H., Jawadi, A. H., Sheiham, A., & Tsakos, G. (2012). Impact of treating dental caries on schoolchildren’s anthropometric, dental, satisfaction and appetite outcomes: a randomized controlled trial. BMC Public Health, 12, 706. https://doi.org/10.1186/1471-2458-12-706

Almajed, O. S., Aljouie, A. A., Alharbi, M. S., & Alsulaimi, L. M. (2024). The Impact of Socioeconomic Factors on Pediatric Oral Health: A Review. Cureus, 16(2), e53567. https://doi.org/10.7759/cureus.53567

Alsumait, A., ElSalhy, M., & Amin, M. (2015). Long-Term Effects of School-Based Oral Health Program on Oral Health Knowledge and Practices and Oral Health-Related Quality of Life. Med Princ Pract, 24(4), 362-368. https://doi.org/10.1159/000430096

Bahanan, L. (2024). Type of insurance coverage and dental sealants among US children: findings from the National Survey of Children’s Health. J Clin Pediatr Dent, 48(6), 181-186. https://doi.org/10.22514/jocpd.2024.138

Blakeney, B. (2023, May 12, 2023). Charleston’s Exodus Gentrification Retrieved September 22, 2025 from https://www.lowcountrypanorama.com/opinion/charlestons-exodus-gentrification-part-1/article_68fc624c-f0a7-11ed-8b0e-fb45d7d07aaa.html

CHSBusiness. (2020, October 21, 2020). MUSC makes $5.6 billion economic impact on state. Charleston Business. Retrieved September 22, 2025 from https://charlestonbusiness.com/musc-makes-56-billion-economic-impact-on-state/

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Education, S. C. D. o. (2024). 2025 Title I School Level Federal Report. South Carolina Department of Education Retrieved from https://ed.sc.gov/districts-schools/student-support/21st-century-community-learning-centers/title-i-schools-served-2025/

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Johnson, B., Serban, N., Griffin, P. M., & Tomar, S. L. (2017). The cost-effectiveness of three interventions for providing preventive services to low-income children. Community Dent Oral Epidemiol, 45(6), 522-528. https://doi.org/10.1111/cdoe.12315

Moore, H. (2025). Charleston tourism hits record $14B, drives South Carolina’s economy. Retrieved September 22, 2025 from https://charlestonbusiness.com/charleston-tourism-growth-2024-impact/

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