A Public Health Update:

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TL;DR

This statewide oral health survey of Delaware kindergarten and third grade children found that 48.3% had tooth decay experience and 20.4% had untreated decay, with significant disparities by race/ethnicity and insurance status. Hispanic/Latinx children (61.2%) and children on Medicaid (59.1%) had significantly higher decay experience than White children (40.4%) and privately insured children (35.5%), respectively. Only 37.5% of third graders had protective dental sealants, below the national average of 42%, highlighting the need for expanded preventive services and dental case management.

Full summary

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**Background:** Oral health is a critical component of overall health, yet access to dental care is often separated from the broader healthcare system. Tooth decay remains a serious public health problem among children, leading to pain, missed school days, and poorer academic performance. The Delaware Bureau of Oral Health and Dental Services (BOHDS) conducted its inaugural statewide oral health survey of kindergarten and third grade children to assess current oral health status and identify disparities.

**Methods:** The survey was conducted during the 2021-2022 school year among children receiving BOHDS dental screenings at 40 schools. A systematic probability proportional to size sampling scheme was used to select 25 third grade schools, with kindergarten feeder schools added for a total of 28 schools representing 25 sampling intervals; 15 additional schools volunteered. Screeners were licensed dentists or dental hygienists trained and calibrated by the Association of State and Territorial Dental Directors (ASTDD). Data collection included direct oral observation and an optional parent questionnaire covering dental insurance, time since last dental visit, toothache history, and unmet care needs. Statistical analyses used complex survey procedures in SAS 9.4 with sample weights to produce population estimates.

**Key Results:** Of 8,847 enrolled children, 3,118 received screenings (35% response rate). Among all children combined, 48.3% (95% CI: 41.4-55.2) had decay experience and 20.4% (95% CI: 13.8-27.0) had untreated decay. Significant disparities were observed: Hispanic/Latinx children had 61.2% decay experience versus 40.4% for White children (p<0.05); Black/African American children had 50.0% and Asian children 50.2%. Children with Medicaid had significantly higher decay experience (59.1%) and untreated decay (26.0%) compared to privately insured children (35.5% and 12.8%, respectively; p<0.05). Children without a dental visit in the past year had 32.2% untreated decay versus 16.4% with a visit (p<0.05). Among those reporting a toothache or cavities in the last year, 79.8% had decay experience and 40.1% had untreated decay. For third graders specifically, 53% had decay experience (below the national average of 60%), 19% had untreated decay (similar to the national average of 20%), and only 37.5% had dental sealants (below the national average of 42%). Kindergarteners had higher-than-national-average rates: 45% with decay experience (national: 42%) and 22% with untreated decay (national: 15%).

**Clinical Implications:** The findings reveal significant oral health inequities in Delaware, with higher disease burden among Hispanic/Latinx children, Black/African American children, and those on Medicaid. The low prevalence of dental sealants (37.5% among third graders) represents a missed preventive opportunity. BOHDS has implemented the Delaware Smile Check Program, which has served over 15,000 children since 2016, providing school-based screenings, education, and case management to connect families to dental homes. The First Smile Delaware Dental Resource Guide was developed in 2020 to help families navigate insurance and find providers. BOHDS plans to evaluate case management effectiveness in late 2023 and conduct the next BSS during the 2026-2027 academic year. Addressing social determinants of health, improving health literacy, and removing barriers to care—including transportation, scheduling, and benefit navigation—are essential to reducing the burden of childhood oral disease in Delaware.