The Hidden Barrier in School-Based Dental Care

A recent JAMA Network Open study of more than 63,000 Medicaid-enrolled children in the Bronx highlighted a troubling paradox in school-based oral health care: children without prior dental visits were less likely to participate in school-based caries prevention programs, even though they may be among the children most likely to benefit.¹

The findings raise an important practical question: if school-based dental programs are designed to reach children who face barriers to care, why are some of those children still missing out? For nonprofit dental clinics delivering care in schools, the answer often begins with the consent process.

When the Form Never Reaches the Parent

The consent problem often starts before a parent has the chance to say yes or no. A paper form placed in a backpack may not make it home. For a parent working long hours, caring for multiple children, or managing an unstable home life, a form can easily disappear.

At Ready Set Smile in Minneapolis, Executive Director Tessa Trepp Wetjen, MPA, MDiv, sees that reality often. “Families have so much coming at them,” she explains. “A consent form can get buried in all the paperwork coming home from school. Some parents may also assume the program isn’t meant for them or that their child doesn’t need it.”

Parents may not check their children’s bookbags or the communication chain is fragile, such as when guardianship changes occur. These are not signs of indifference, but rather that the one-time paper form is too fragile a system for families whose lives may include shifting contact information, multiple caregivers, transportation challenges, or other competing demands.

Parents May Be Overwhelmed, Not Uninterested

One risk in discussing low consent return rates is that the conversation can quickly become judgmental. Even within dentistry, assumptions about parents whose children have untreated dental disease are common.

The providers working closest to these families describe a different picture. Holly Jorgensen, CRDH, executive director of Let’s Smile Inc in Owatonna, Minnesota, notes the most common barriers are usually about access, communication, and life circumstances. “The children who need care the most are often in families experiencing the highest levels of instability,” she explains. “That instability directly affects whether a form gets home, whether contact information is current, and whether a parent has the time and clarity to respond.”

Confusion About What School-Based Dental Care Provides

Parents may not understand the difference between a school dental screening and enrollment in a comprehensive school-based dental program. For families who have limited experience navigating dental care, the distinctions that seem obvious to oral health professionals may not be clear.

Wanda Cloet, DHSc, RDH, director of the Dental Hygiene Program at Central Community College in Hastings, Nebraska, offers a telling example. She heard from a parent who assumed that because her child sees an orthodontist, preventive services were already being provided.

“To those of us in dentistry, it sounds almost funny because we know orthodontic care and preventive care are completely different,” Cloet says. “But for parents, it can all fall under the same broad category of ‘dental.’ That tells us we need to do a better job explaining what services are being offered and why they matter.”

Families may also confuse an annual school dental screening with enrollment in a more comprehensive school-based dental program. That distinction matters because parents may believe their child has already received care when the screening was only the first step.

Other misconceptions involve the care setting itself. Some parents may ask whether actual dentists provide care through mobile programs, while others doubt that restorative services can be performed in dental vans.

When children are not in pain, the risk of forgoing care is even higher. Some parents do not understand why primary teeth need treatment if they will eventually fall out. Consent materials should not merely request permission. They should help parents understand why care matters, what services will be provided, and what happens if additional treatment is needed.

The Fear of a Bill Later

Even when services are free or covered, families may be cautious. Many have experienced confusing medical bills, insurance limitations, or unexpected charges. For those families, signing a healthcare-related form may feel risky.

Programs may need to be more explicit than they think. A single phrase such as “free dental care” may not be enough; families may need repeated reassurance that they will not receive a surprise bill.

Consent Is an Act of Trust

For many parents, especially those who have had negative experiences with healthcare systems, school systems, or government-related paperwork, signing a form may raise concerns that go beyond dentistry. Undocumented families may be hesitant to sign forms because of fears about immigration enforcement. Others may have a broader distrust of healthcare systems or school-based programs.

Several providers said families sometimes want to be there during the child’s appointment. Others want reassurance that treatment will not be forced if a child is afraid, uncomfortable, or resistant. These concerns deserve respect.

Programs can help by clearly explaining what happens during the visit, who provides care, how children are comforted, what services may be performed, and how parents will be contacted if additional needs are found.

The Bigger Question: Will This Actually Help?

For families facing significant barriers, agreeing to a school-based dental visit may raise another concern: what happens if the program finds a cavity or identifies a treatment need? A screening without an accessible care pathway can feel like one more problem to solve. Parents may already suspect their child needs care. But if they do not know where to go, how to pay, how to get time off work, or how to arrange transportation, confirmation of the problem may feel overwhelming rather than helpful.

This is why the connection to a dental home matters. Children need more than a one-time free care event. A dental home provides an ongoing relationship and continuity of care with a dental provider or clinic where children can receive preventive care, treatment, follow-up, and support over time.

The JAMA study and the field experience of school-based providers point to the same concern: the children most likely to benefit from school-based care may still be missed when participation depends on systems that do not reflect family realities. The answer lies in building consent systems that recognize the barriers families face before a child ever sits in the dental chair.

Reference

1. Huang SS, Ruff RR, Gold HT, Wang SS. School-based caries prevention programs and recruitment of high-risk pediatric Medicaid populations. JAMA Network Open. 2026;9:e265996