Journal of Public Health Dentistry . ISSN 0022-4006
Oral health status and academic performance among Ohio third-graders, 2009-2010 Amber M.R. Detty, MA1; Reena Oza-Frank, PhD, RD2 1 Oral Health Section, Bureau of Community Health Services and Patient-Centered Primary Care, Ohio Department of Health, Columbus, OH, USA 2 Research Institute at Nationwide Children’s Hospital, Department of Pediatrics, The Ohio State University, Columbus, OH, USA
Keywords academic performance; schools; oral health; dental caries; dental decay. Correspondence Ms. Amber M.R. Detty, Oral Health Section, Bureau of Community Health Services and Patient-Centered Primary Care, Ohio Department of Health, 246 N. High Street, Columbus, OH 43215. Tel.: (614) 644-9598; Fax: (614) 564-2421; e-mail: [email protected]. Reena Oza-Frank is with the Research Institute at Nationwide Children’s Hospital, Department of Pediatrics, The Ohio State University. Received: 8/2/2013; accepted: 5/4/2014. doi: 10.1111/jphd.12063 Journal of Public Health Dentistry 74 (2014) 336–342
Abstract Objective: Although recent literature indicated an association between dental caries and poor academic performance, previous work relied on self-reported measures. This analysis sought to determine the association between academic performance and untreated dental caries (tooth decay) using objective measures, controlling for school-level characteristics. Methods: School-level untreated caries prevalence was estimated from a 2009-2010 oral health survey of Ohio third-graders. Prevalence estimates were combined with school-level academic performance and other school characteristics obtained from the Ohio Department of Education. Linear regression models were developed as a result of bivariate testing, and final models were stratified based upon the presence of a school-based dental sealant program (SBSP). Results: Preliminary bivariate analysis indicated a significant relationship between untreated caries and academic performance, which was more pronounced at schools with an SBSP. After controlling for other school characteristics, the prevalence of untreated caries was found to be a significant predictor of academic performance at schools without an SBSP (P = 0.001) but not at schools with an SBSP (P = 0.833). Conclusions: The results suggest the association between untreated caries and academic performance may be affected by the presence of a school-based oral health program. Further research focused on oral health and academic performance should consider the presence and/or availability of these programs.
Introduction While it remains clear that dental disease is still a common childhood health concern, especially for vulnerable populations (1-4), research on the impact of dental disease on children’s academics remains sparse. Self-reported dental disease has been associated with poor academic performance in recent literature (5,6). Specifically, in regional studies, parents who reported their child’s oral health status as poor were more likely to report poorer school performance compared with those with good oral and general health status (5,6). This association was not mediated by school absence resulting from dental pain, indicating that the association between poor oral health and performance exists independently of school absence (6). The sparse previous research has focused only on self- or parent-reported oral health and school performance. While some studies suggest that self- or parent-reported oral health 336
assessments may be an acceptable proxy for general oral health status (7), others have found that self-reports of dental caries may not be as valid as clinical assessments (8). Parentand self-reported dental caries have been found to be underestimated, even within populations with greater health-care access and awareness (8). Thus, underreporting of dental caries may be even greater among those without regular access to care. Self-reporting of school performance has similar drawbacks. A meta-analysis revealed that while selfand parent-reported grades are reasonably valid for students at all grade levels with high ability and grade point averages (GPAs), they are unlikely to be valid for students with low GPAs (9). Thus, previous research relying on self-reported oral health and school performance may underestimate or not detect any association. Among Ohio children, dental care remains the single most common unmet health care need (10). Specifically, 51 percent of Ohio children have experienced dental caries by third © 2014 American Association of Public Health Dentistry
A.M.R. Detty and R. Oza-Frank
grade, and 19 percent of third-graders have untreated caries (10). The Ohio Department of Health (ODH) Oral Health Program has been monitoring the oral health of third-grade children throughout the state since 1987. ODH Oral Health Program has also been supporting school-based sealant programs (SBSPs) since 1987 (11). Public health-funded SBSPs in Ohio provide a dental screening and dental sealants in schools where more than 40 percent of students participate in the National School Lunch Program (NSLP) and there is a capable and willing local agency to administer the program. In Ohio, sealant programs cover about 55 percent of eligible schools in the state and are concentrated mostly in urban and Appalachian counties (11). SBSPs primarily serve children in second and sixth grades, following up with children in third and seventh grades to ensure proper sealant retention and to seal any permanent molars not sufficiently erupted or sealed the previous school year. The program provides preventive services; children are also assessed for restorative treatment needs, and parents and school nurses are informed and encouraged to obtain any needed care for children participating in the program. SBSPs provide effective screening and preventive services while limiting children’s time out of the classroom and allowing them to remain in school. It is possible that the presence of these programs may affect the association between untreated caries and school performance; however, this has yet to be studied. Just prior to the start of the 2009-2010 Ohio oral health survey, school-level academic scores became publicly accessible through the Ohio Department of Education (ODE) website, presenting a new opportunity to assess the impact of dental disease prevalence on school-level academic performance using linking clinical oral health screening data and state academic test scores. The objective of this study was to determine the association between academic performance and untreated caries controlling for other school-level health and demographic characteristics, including presence of an SBSP, among Ohio’s third-grade children.
Methods Study design During the 2009-2010 school year, ODH conducted a statewide survey of oral health among third-grade children as part of ongoing surveillance of this population consistent with other state and national programs. Methods of the survey have been previously published (10,12). Briefly, the survey employed a stratified cluster sample design, where public, noncharter schools (charter schools are independently operated, publicly funded, tuition-free public schools that are created on the basis of a contract or “charter”) were chosen within each of Ohio’s 88 counties by probability proportional to size sampling with replacement. Schools within each © 2014 American Association of Public Health Dentistry
Oral health and performance among Ohio third-graders
county were further divided into substrata based on their level of participation in the NSLP (fewer than 50 percent or 50 percent or more of students participating in NSLP) (12). NSLP participation is used because it is associated with oral health, it varies across Ohio counties, and it ensures equal representation of lower- and upper-income schools when possible (10,12). All third-graders at the selected schools were eligible to participate with parental permission. A total of 377 schools were selected for participation in the 2009-2010 survey to generate state- and county-level estimates. In the event that schools were not able to or declined to be involved in the survey, replacement schools were chosen. For the 20092010 survey, the overall school-level response rate was 89.9 percent (2.7 percent of schools closed or restructured, 7.4 percent declined participation), and student-level response rate was 50.0 percent. The third-grade oral health surveillance program was approved by the ODH Human Subjects Internal Review Board.
Dependent variable Measure of school performance was available through ODE as a building performance index score (13). The performance index rewards the achievement of every student, not just those who score proficient or higher on one or two subjectspecific tests. Traditional school districts and school buildings, including community schools, earn points based on how well each student does on all tested subjects in grades 3-8 on Ohio’s Achievement Assessments and on the 10th grade Ohio Graduation Test. All assessments have five performance levels that include advanced, accelerated, proficient, basic, and limited. The percentage of students scoring at each performance level is calculated and then multiplied by the point value assigned to that performance level. The points earned for each performance level are totaled to determine each school’s performance index score. Performance index scores can range from 0 to 120 and average 93.3 in all Ohio public schools. In the population of schools with third-grade students, the average performance index score in 2009-2010 was 92.4, with 25 percent of schools scoring below an 85.9 and 25 percent of schools scoring above 101.6.
Independent variable An open-mouth oral health screening was conducted by trained oral health professionals according to the Basic Screening Surveys (BSS) methodology (14), which is widely used by state dental programs. The BSS methodology collects prevalence data through observation by a screener (dentists and dental hygienists in this survey) using a light source and disposable mirrors to directly observe and record whether children had one or more decayed teeth (untreated dental caries). The individual student-level untreated caries 337
Oral health and performance among Ohio third-graders
indicator was then aggregated into a school-level prevalence of untreated caries for use in this analysis.
School-level characteristics Low income, racial minority, and enrollment were all gathered from data made available by ODE for the 2009-2010 academic year. Low income was defined based on the previously defined percentage of students enrolled in the NSLP. School-level racial minority composition was measured by the percentage of students who were not identified as Caucasian. Enrollment was measured by the total number of third-graders enrolled in the school at the time of the screening. Geographic designations were defined using Ohiospecific county types: Appalachian (as designated by the Appalachian Regional Commission) (15), metropolitan (a non-Appalachian county that contains at least one city with 50,000 or more inhabitants), suburban (a nonmetropolitan, non-Appalachian county that meets the U.S. Census definition of an urbanized area), and rural/non-Appalachian (all other counties not classified as Appalachian, metropolitan or suburban). Schools with a public health SBSP during the time of the survey were identified through program data maintained by ODH. Schools were counted as having an SBSP if second graders received sealants in the previous school year (20082009; these students were third-graders in 2009-2010).
Statistical analyses While sample weights were calculated at the student level, this analysis was conducted using school-level variables. Therefore, weights for each school were aggregated into an average weight for all students within that school to be used in this school-level analysis. Student-level sample weights were calculated to be representative of the underlying population in regards to income and race, and they included adjustment for survey nonresponse. Bivariate associations were first explored among the dependent variable, independent variable, and school-level characteristics. Significant differences in mean performance index scores were determined using t-tests after confirming a normal distribution of mean performance index scores. Linear regression was used to assess the association between untreated caries and academic performance, controlling for the previously mentioned school-level characteristics. Regression coefficients and P values were used to test for significance of associations between all variables of interest and the outcome. Although attendance rates have been shown to be associated with child health (5,6), in this study there was very little variation in school-level aggregate attendance rates (96-97% 338
A.M.R. Detty and R. Oza-Frank
student attendance across the school year at almost all schools). As a result, attendance rates were highly correlated with the intercepts of each model and created inflated standard errors. Therefore, attendance rates were not included in the models. Using Pearson’s correlation coefficients and variance inflation factor scores, it was determined that no other independent variables demonstrated significant multicollinearity in the models. All statistical analyses were completed using SAS 9.2 survey procedures.
Results During the 2009-2010 school year, there were 16,022 thirdgraders screened (50% response rate) in 377 schools in Ohio. The average school prevalence of untreated dental caries among third-grade students was 20.7%, and 25.2% of the schools had an SBSP (Table 1). The average prevalence of untreated dental caries was higher at schools with an SBSP than those without an SBSP (25.1% versus 19.2%, respectively). The average school performance index score was 98.8 and higher at schools without an SBSP than at schools with an SBSP (99.0 versus 90.2, respectively). Preliminary bivariate analysis indicated associations between untreated caries and school performance (t = −2.07, P = 0.04). Specifically, at schools with higher prevalence of untreated caries, students experienced poorer performance. The association between untreated caries and school performance was also more pronounced in schools without an SBSP than those with one (Figure 1). Multivariate linear regression showed that when controlling for low income, racial minority, enrollment, county type, and the presence of an SBSP, the association between untreated caries and academic performance was not statistically significant but approached significance (P = 0.09). Specifically, low-income schools, more racial minorities, lower enrollment, suburban county (versus metropolitan county), and presence of an SBSP were all significantly associated with poorer school performance (P < 0.05 for all) (Table 2). While the interaction between untreated caries and SBSP was not statistically significant (P = 0.23), stratified models may have public health significance because the bivariate association between untreated caries and academic performance differed based on presence of an SBSP, as noted above. In stratified analyses, untreated caries was not significantly associated with performance at schools with an SBSP (P = 0.83). Low income, the percentage of racial minority students, and being located in a suburban county were all significantly inversely associated with school performance at schools with an SBSP (P < 0.05 for all). A one-percentage-point increase in the proportion of low-income students was associated with a 22.8-point-lower performance index score and a onepercentage-point increase in the proportion of racial minority students was associated with a 18.8-point-lower © 2014 American Association of Public Health Dentistry
A.M.R. Detty and R. Oza-Frank
Oral health and performance among Ohio third-graders
Table 1 School-Level Characteristics (n = 377)
All schools Low income* Racial minority* Untreated caries Appalachian county† Rural county† Suburban county† Metropolitan county† Enrollment (mean) Sealant program Performance index score (mean)*‡ Attendance*¶ (mean)
40.9 9.4 20.7 26.8 29.4 24.9 18.8 85.1 25.2 98.8 94.8
School with sealant program (n = 95)
Schools without sealant program (n = 282)
59.6 13.6 25.1 14.6 1.9 2.1 6.6 75.1
33.7 8.0 19.2 12.2 27.6 22.8 12.2 88.4
90.2 94.5
99.0 94.9
All data given as percentages. * School-level characteristics (low income, racial minority, enrollment, performance index score, attendance) were obtained through the Ohio Department of Education. † Appalachian: as designated by the Appalachian Regional Commission (15); metropolitan: a nonAppalachian county that contains at least one city with 50,000 or more inhabitants; suburban: a nonmetropolitan, non-Appalachian county that meets the U.S. Census definition of an urbanized area; rural/non-Appalachian: all other counties not classified as Appalachian, metropolitan, or suburban. ‡ Measure of school performance was available through Ohio Department of Education as score (13). All assessments have five performance levels, which include advanced, accelerated, proficient, basic, and limited. The percentage of students scoring at each performance level is calculated and then multiplied by the point value assigned to that performance level. The points earned for each performance level are totaled to determine each schools performance index score. ¶ Attendance is an aggregate measure for each school building and has little variation, with rates ranging from 91.2 to 95.0 for all 377 schools in the sample. This low variation creates collinearity with the intercept in all regression models; thus, attendance was not included in any multivariate models for this analysis.
Figure 1 School mean performance index score by untreated caries prevalence. *Statistically significantly different from Low Untreated Caries (
Oral health status and academic performance among Ohio third-graders, 2009-2010 Amber M.R. Detty, MA1; Reena Oza-Frank, PhD, RD2 1 Oral Health Section, Bureau of Community Health Services and Patient-Centered Primary Care, Ohio Department of Health, Columbus, OH, USA 2 Research Institute at Nationwide Children’s Hospital, Department of Pediatrics, The Ohio State University, Columbus, OH, USA
Keywords academic performance; schools; oral health; dental caries; dental decay. Correspondence Ms. Amber M.R. Detty, Oral Health Section, Bureau of Community Health Services and Patient-Centered Primary Care, Ohio Department of Health, 246 N. High Street, Columbus, OH 43215. Tel.: (614) 644-9598; Fax: (614) 564-2421; e-mail: [email protected]. Reena Oza-Frank is with the Research Institute at Nationwide Children’s Hospital, Department of Pediatrics, The Ohio State University. Received: 8/2/2013; accepted: 5/4/2014. doi: 10.1111/jphd.12063 Journal of Public Health Dentistry 74 (2014) 336–342
Abstract Objective: Although recent literature indicated an association between dental caries and poor academic performance, previous work relied on self-reported measures. This analysis sought to determine the association between academic performance and untreated dental caries (tooth decay) using objective measures, controlling for school-level characteristics. Methods: School-level untreated caries prevalence was estimated from a 2009-2010 oral health survey of Ohio third-graders. Prevalence estimates were combined with school-level academic performance and other school characteristics obtained from the Ohio Department of Education. Linear regression models were developed as a result of bivariate testing, and final models were stratified based upon the presence of a school-based dental sealant program (SBSP). Results: Preliminary bivariate analysis indicated a significant relationship between untreated caries and academic performance, which was more pronounced at schools with an SBSP. After controlling for other school characteristics, the prevalence of untreated caries was found to be a significant predictor of academic performance at schools without an SBSP (P = 0.001) but not at schools with an SBSP (P = 0.833). Conclusions: The results suggest the association between untreated caries and academic performance may be affected by the presence of a school-based oral health program. Further research focused on oral health and academic performance should consider the presence and/or availability of these programs.
Introduction While it remains clear that dental disease is still a common childhood health concern, especially for vulnerable populations (1-4), research on the impact of dental disease on children’s academics remains sparse. Self-reported dental disease has been associated with poor academic performance in recent literature (5,6). Specifically, in regional studies, parents who reported their child’s oral health status as poor were more likely to report poorer school performance compared with those with good oral and general health status (5,6). This association was not mediated by school absence resulting from dental pain, indicating that the association between poor oral health and performance exists independently of school absence (6). The sparse previous research has focused only on self- or parent-reported oral health and school performance. While some studies suggest that self- or parent-reported oral health 336
assessments may be an acceptable proxy for general oral health status (7), others have found that self-reports of dental caries may not be as valid as clinical assessments (8). Parentand self-reported dental caries have been found to be underestimated, even within populations with greater health-care access and awareness (8). Thus, underreporting of dental caries may be even greater among those without regular access to care. Self-reporting of school performance has similar drawbacks. A meta-analysis revealed that while selfand parent-reported grades are reasonably valid for students at all grade levels with high ability and grade point averages (GPAs), they are unlikely to be valid for students with low GPAs (9). Thus, previous research relying on self-reported oral health and school performance may underestimate or not detect any association. Among Ohio children, dental care remains the single most common unmet health care need (10). Specifically, 51 percent of Ohio children have experienced dental caries by third © 2014 American Association of Public Health Dentistry
A.M.R. Detty and R. Oza-Frank
grade, and 19 percent of third-graders have untreated caries (10). The Ohio Department of Health (ODH) Oral Health Program has been monitoring the oral health of third-grade children throughout the state since 1987. ODH Oral Health Program has also been supporting school-based sealant programs (SBSPs) since 1987 (11). Public health-funded SBSPs in Ohio provide a dental screening and dental sealants in schools where more than 40 percent of students participate in the National School Lunch Program (NSLP) and there is a capable and willing local agency to administer the program. In Ohio, sealant programs cover about 55 percent of eligible schools in the state and are concentrated mostly in urban and Appalachian counties (11). SBSPs primarily serve children in second and sixth grades, following up with children in third and seventh grades to ensure proper sealant retention and to seal any permanent molars not sufficiently erupted or sealed the previous school year. The program provides preventive services; children are also assessed for restorative treatment needs, and parents and school nurses are informed and encouraged to obtain any needed care for children participating in the program. SBSPs provide effective screening and preventive services while limiting children’s time out of the classroom and allowing them to remain in school. It is possible that the presence of these programs may affect the association between untreated caries and school performance; however, this has yet to be studied. Just prior to the start of the 2009-2010 Ohio oral health survey, school-level academic scores became publicly accessible through the Ohio Department of Education (ODE) website, presenting a new opportunity to assess the impact of dental disease prevalence on school-level academic performance using linking clinical oral health screening data and state academic test scores. The objective of this study was to determine the association between academic performance and untreated caries controlling for other school-level health and demographic characteristics, including presence of an SBSP, among Ohio’s third-grade children.
Methods Study design During the 2009-2010 school year, ODH conducted a statewide survey of oral health among third-grade children as part of ongoing surveillance of this population consistent with other state and national programs. Methods of the survey have been previously published (10,12). Briefly, the survey employed a stratified cluster sample design, where public, noncharter schools (charter schools are independently operated, publicly funded, tuition-free public schools that are created on the basis of a contract or “charter”) were chosen within each of Ohio’s 88 counties by probability proportional to size sampling with replacement. Schools within each © 2014 American Association of Public Health Dentistry
Oral health and performance among Ohio third-graders
county were further divided into substrata based on their level of participation in the NSLP (fewer than 50 percent or 50 percent or more of students participating in NSLP) (12). NSLP participation is used because it is associated with oral health, it varies across Ohio counties, and it ensures equal representation of lower- and upper-income schools when possible (10,12). All third-graders at the selected schools were eligible to participate with parental permission. A total of 377 schools were selected for participation in the 2009-2010 survey to generate state- and county-level estimates. In the event that schools were not able to or declined to be involved in the survey, replacement schools were chosen. For the 20092010 survey, the overall school-level response rate was 89.9 percent (2.7 percent of schools closed or restructured, 7.4 percent declined participation), and student-level response rate was 50.0 percent. The third-grade oral health surveillance program was approved by the ODH Human Subjects Internal Review Board.
Dependent variable Measure of school performance was available through ODE as a building performance index score (13). The performance index rewards the achievement of every student, not just those who score proficient or higher on one or two subjectspecific tests. Traditional school districts and school buildings, including community schools, earn points based on how well each student does on all tested subjects in grades 3-8 on Ohio’s Achievement Assessments and on the 10th grade Ohio Graduation Test. All assessments have five performance levels that include advanced, accelerated, proficient, basic, and limited. The percentage of students scoring at each performance level is calculated and then multiplied by the point value assigned to that performance level. The points earned for each performance level are totaled to determine each school’s performance index score. Performance index scores can range from 0 to 120 and average 93.3 in all Ohio public schools. In the population of schools with third-grade students, the average performance index score in 2009-2010 was 92.4, with 25 percent of schools scoring below an 85.9 and 25 percent of schools scoring above 101.6.
Independent variable An open-mouth oral health screening was conducted by trained oral health professionals according to the Basic Screening Surveys (BSS) methodology (14), which is widely used by state dental programs. The BSS methodology collects prevalence data through observation by a screener (dentists and dental hygienists in this survey) using a light source and disposable mirrors to directly observe and record whether children had one or more decayed teeth (untreated dental caries). The individual student-level untreated caries 337
Oral health and performance among Ohio third-graders
indicator was then aggregated into a school-level prevalence of untreated caries for use in this analysis.
School-level characteristics Low income, racial minority, and enrollment were all gathered from data made available by ODE for the 2009-2010 academic year. Low income was defined based on the previously defined percentage of students enrolled in the NSLP. School-level racial minority composition was measured by the percentage of students who were not identified as Caucasian. Enrollment was measured by the total number of third-graders enrolled in the school at the time of the screening. Geographic designations were defined using Ohiospecific county types: Appalachian (as designated by the Appalachian Regional Commission) (15), metropolitan (a non-Appalachian county that contains at least one city with 50,000 or more inhabitants), suburban (a nonmetropolitan, non-Appalachian county that meets the U.S. Census definition of an urbanized area), and rural/non-Appalachian (all other counties not classified as Appalachian, metropolitan or suburban). Schools with a public health SBSP during the time of the survey were identified through program data maintained by ODH. Schools were counted as having an SBSP if second graders received sealants in the previous school year (20082009; these students were third-graders in 2009-2010).
Statistical analyses While sample weights were calculated at the student level, this analysis was conducted using school-level variables. Therefore, weights for each school were aggregated into an average weight for all students within that school to be used in this school-level analysis. Student-level sample weights were calculated to be representative of the underlying population in regards to income and race, and they included adjustment for survey nonresponse. Bivariate associations were first explored among the dependent variable, independent variable, and school-level characteristics. Significant differences in mean performance index scores were determined using t-tests after confirming a normal distribution of mean performance index scores. Linear regression was used to assess the association between untreated caries and academic performance, controlling for the previously mentioned school-level characteristics. Regression coefficients and P values were used to test for significance of associations between all variables of interest and the outcome. Although attendance rates have been shown to be associated with child health (5,6), in this study there was very little variation in school-level aggregate attendance rates (96-97% 338
A.M.R. Detty and R. Oza-Frank
student attendance across the school year at almost all schools). As a result, attendance rates were highly correlated with the intercepts of each model and created inflated standard errors. Therefore, attendance rates were not included in the models. Using Pearson’s correlation coefficients and variance inflation factor scores, it was determined that no other independent variables demonstrated significant multicollinearity in the models. All statistical analyses were completed using SAS 9.2 survey procedures.
Results During the 2009-2010 school year, there were 16,022 thirdgraders screened (50% response rate) in 377 schools in Ohio. The average school prevalence of untreated dental caries among third-grade students was 20.7%, and 25.2% of the schools had an SBSP (Table 1). The average prevalence of untreated dental caries was higher at schools with an SBSP than those without an SBSP (25.1% versus 19.2%, respectively). The average school performance index score was 98.8 and higher at schools without an SBSP than at schools with an SBSP (99.0 versus 90.2, respectively). Preliminary bivariate analysis indicated associations between untreated caries and school performance (t = −2.07, P = 0.04). Specifically, at schools with higher prevalence of untreated caries, students experienced poorer performance. The association between untreated caries and school performance was also more pronounced in schools without an SBSP than those with one (Figure 1). Multivariate linear regression showed that when controlling for low income, racial minority, enrollment, county type, and the presence of an SBSP, the association between untreated caries and academic performance was not statistically significant but approached significance (P = 0.09). Specifically, low-income schools, more racial minorities, lower enrollment, suburban county (versus metropolitan county), and presence of an SBSP were all significantly associated with poorer school performance (P < 0.05 for all) (Table 2). While the interaction between untreated caries and SBSP was not statistically significant (P = 0.23), stratified models may have public health significance because the bivariate association between untreated caries and academic performance differed based on presence of an SBSP, as noted above. In stratified analyses, untreated caries was not significantly associated with performance at schools with an SBSP (P = 0.83). Low income, the percentage of racial minority students, and being located in a suburban county were all significantly inversely associated with school performance at schools with an SBSP (P < 0.05 for all). A one-percentage-point increase in the proportion of low-income students was associated with a 22.8-point-lower performance index score and a onepercentage-point increase in the proportion of racial minority students was associated with a 18.8-point-lower © 2014 American Association of Public Health Dentistry
A.M.R. Detty and R. Oza-Frank
Oral health and performance among Ohio third-graders
Table 1 School-Level Characteristics (n = 377)
All schools Low income* Racial minority* Untreated caries Appalachian county† Rural county† Suburban county† Metropolitan county† Enrollment (mean) Sealant program Performance index score (mean)*‡ Attendance*¶ (mean)
40.9 9.4 20.7 26.8 29.4 24.9 18.8 85.1 25.2 98.8 94.8
School with sealant program (n = 95)
Schools without sealant program (n = 282)
59.6 13.6 25.1 14.6 1.9 2.1 6.6 75.1
33.7 8.0 19.2 12.2 27.6 22.8 12.2 88.4
90.2 94.5
99.0 94.9
All data given as percentages. * School-level characteristics (low income, racial minority, enrollment, performance index score, attendance) were obtained through the Ohio Department of Education. † Appalachian: as designated by the Appalachian Regional Commission (15); metropolitan: a nonAppalachian county that contains at least one city with 50,000 or more inhabitants; suburban: a nonmetropolitan, non-Appalachian county that meets the U.S. Census definition of an urbanized area; rural/non-Appalachian: all other counties not classified as Appalachian, metropolitan, or suburban. ‡ Measure of school performance was available through Ohio Department of Education as score (13). All assessments have five performance levels, which include advanced, accelerated, proficient, basic, and limited. The percentage of students scoring at each performance level is calculated and then multiplied by the point value assigned to that performance level. The points earned for each performance level are totaled to determine each schools performance index score. ¶ Attendance is an aggregate measure for each school building and has little variation, with rates ranging from 91.2 to 95.0 for all 377 schools in the sample. This low variation creates collinearity with the intercept in all regression models; thus, attendance was not included in any multivariate models for this analysis.
Figure 1 School mean performance index score by untreated caries prevalence. *Statistically significantly different from Low Untreated Caries (
