Best Practice Approach Reports
School-based Dental Sealant Programs
A Best Practice Approach Report describes a public health strategy, assesses the strength of evidence on the effectiveness of the strategy, and uses practice examples to illustrate successful/innovative implementation.
Report last updated: June 16, 2003
II. Guidelines & Recommendations
III. Research Evidence
IV. Best Practice Criteria
V. State Practice Examples
A. Dental Sealants
Dental sealants are clear or opaque plastic materials applied to the pit-and-fissure surfaces of teeth to prevent decay (dental caries). Sealants provide a physical barrier that prevents debris and decay-causing bacteria from collecting in the pits and fissures of vulnerable teeth (mainly molars). These areas are often the first and most frequent sites to be affected by tooth decay in children and adolescents. National estimates show that as much as 90% of all dental caries in schoolchildren occurs in pits and fissures (1). The permanent first and second molars are at the highest risk for tooth decay (2).
To be most effective, sealants should be placed on teeth soon after they erupt. Sealants are helpful for persons at increased risk for tooth decay such as those with medical conditions associated with higher caries rates, children who have experienced extensive caries in their primary teeth, and children who already have incipient caries in a permanent molar tooth (2).
Studies have evaluated the placement of sealants on tooth surfaces with caries (2). Heller et al. (5) evaluated the effect of sealants placed on permanent first molar teeth through a school-based program after five years. The 5-year tooth decay rate was lower for sealed tooth surfaces with incipient caries compared to unsealed tooth surfaces (10.8 percent versus 51.8 percent). Mertz-Fairhurst et al. (6) reported a 10-year study that showed caries did not progress under a dental sealant placed over cavitated lesions that were no more than halfway through the dentin of the tooth.The most recent National Health and Nutrition Examination Survey (NHANES) showed that during 1988-1991, 18.5% of U.S. children, ages 5-17, had one or more sealed permanent teeth. Molar teeth were the most frequently sealed. A significantly higher percentage of non-Hispanic whites had sealants in comparison with their non-Hispanic black and Mexican-American counterparts (7).
B. Dental Sealant Programs
Dental sealant programs generally provide sealants to vulnerable populations less likely to receive private dental care, such as children eligible for free or reduced-cost lunch programs (2).
There are variations in how dental sealant programs are designed:
Synopses of State and Territorial Dental Public Health Programs showed that in 2001-2002, 35 states and 4 territories reported having programs for dental sealants (in one or more of the program design variations described above). The states include: AL, AZ, CA, CO, CT, GA, ID, IL, IN, IA, KY, LA, ME, MD, MA, MN, MO, NE, NV, NH, NJ, NM, NY, NC, ND, OH, OK, OR, RI, UT, VT, VA, WV, WI, and WY. The territories include American Samoa, Guam, N. Mariana Islands, and Republic of Palau (8).
The 2003 Oral Health Report Card (9), published by the Oral Health America National Grading Project to call greater policy attention to oral health needs, graded states on their statewide sealant programs. The grading is based on the percentage of a population of caries-risk children (e.g., minority, low-income, Medicaid eligible, lunch program eligible and/or without insurance) served by the sealant program. The following was reported for the states and District of Columbia:
C. School-based Dental Sealant Programs
A school preventive oral health program may incorporate several elements, such as oral health education, dental screenings, referral for dental treatment, fluoride mouthrinsing and sealant applications. Primary dental care programs in school settings will also apply sealants as part of basic restorative and preventive dental treatment. This best practice approach report, however, will describe only school-based programs for which sealant application is the primary program objective.
A state dental program's role in school sealant programs may take the form of: (a) providing direct service delivery, (b) funding grants or contracts to deliver sealants, (c) managing a state-level program that does not provide direct service but pay for services such as through vouchers, (d) setting standards for local direct service sealant programs, and/or (e) facilitating and promoting private-public sealant program partnerships (e.g., schools and dental societies).
The following description of a school-based dental sealant program shows the attributes of a direct service delivery program, whether operated by a state or local agency or an organization:
Healthy People 2010 Oral Health Objective 21-8 calls for 50 percent of eight and 14 year-old children to have sealants on their permanent molar teeth (10). The Healthy People 2010 sealant objective and sealant programs focus on permanent molars because caries risk on other teeth with pits and fissures is considerably lower. Although sealants can be placed on children's premolars, maxillary incisors and primary molars, the situations in which such use would be appropriate are limited.
The Surgeon General's Report on Oral Health found that studies suggest that sealants are an efficient use of resources when used in populations with higher-than-average disease incidence rates and when sealants are placed on teeth at highest risk for caries (2).
The 1995 Workshop on Guidelines for Sealant Use distinguished community-based sealant programs (including school-based and school-linked programs) from individual care programs (private practice and public clinics). People treated in community programs are more likely to be episodic users of primary dental care services. Furthermore, community sealant programs do not provide continuous care nor do they have access to a full array of caries diagnostic and treatment options (11).
In its systematic review of the literature, the Task Force on Community Preventive Services (2002) found that school sealant programs are effective in reducing tooth decay. The median decrease in caries on the occlusal (chewing) surfaces of posterior teeth in children was 60%. Based on this review, the Task Force issued a strong recommendation that school sealant programs be included as part of a comprehensive population-based strategy to prevent or control tooth decay in communities (3).
A literature review of pit and fissure sealant in 2002 included 1,465 peer-reviewed publications from 1971 to October 2001 and reported that (12):
- It is clear that sealants are safe, effective and underused (in the United States), and
- Pit and fissure sealant is best applied to high-risk populations by trained auxiliaries using sealant that incorporates the benefit of an intermediate bonding layer, applied under the rubber dam or with some alternative short-term and effective isolation technique, and placed on tooth enamel (outer tooth surface) that has been cleaned and etched.
An analysis of nine clinical studies with a randomized, half-mouth, clinical trial design and seven studies with observational study designs found good evidence that sealants are efficacious and effective in high-caries-risk children as long as the sealant is retained (4). Sealants are more effective in preventing further caries and providing cost savings in a shorter time span if placed in children who have high rather than low caries risk.
Another comparison on the costs of sealant delivery strategies also showed that among high-risk populations for dental caries, less cost and reduced caries results from placing sealants on all children of a high-risk population versus only placing sealants for those children assessed to be at risk by individual screening (13). Among low-risk populations for dental caries, less cost results from placing sealants only for children assessed to be at risk by individual screening, compared to the strategies of placing sealants on all children or not providing any sealants.
For the best practice approach of School-based Dental Sealant Programs, the ASTDD Best Practices Committee has proposed the following initial review standards for five best practice criteria:
- The program delivers to large numbers of high-risk children with susceptible permanent molar teeth.
- The program maintains a quality assurance system that includes technical quality (the sealants placed have a high rate of retention) and appropriateness (the children receiving sealants are at high caries risk).
- The program uses the least expensive personnel permitted by state laws to screen children and deliver dental sealants with adequate training and quality assurance.
3. Demonstrated Sustainability
- The program demonstrates sustainability by establishing a track record or a reasonable plan for covering program expenses.
- Collaborative partnerships are established to administer and sustain the program.
- The program's goals and objectives are linked to the state and/or national oral health goals and objectives.
During the first phase of the ASTDD Best Practices Project, states submitted descriptions of their successful practices to share their experiences and implementation strategies. The following practice examples illustrate various elements or dimensions of the best practice approach for School-based Dental Sealant Programs. These reported success stories should be viewed in the context of the state's and program's environment, infrastructure and resources. End-users are encouraged to review the practice descriptions (click on the links of the practice names) and adapt ideas for a better fit to their states and programs.
A. Summary Listing of Practice Examples
|In FY 2001-2002, four states submitted practice descriptions of their school-based dental sealant programs to the ASTDD Best Practices Committee. The Arizona, Illinois, New Mexico and Ohio sealant programs illustrate substantial elements of the model school-based sealant program described in Section II. See Figure 1. Each practice name is linked to a detailed description report.
| Figure 1.
State Practice Examples of
School-based Dental Sealant Programs
B. Highlights of the Practice Examples
This report is the result of efforts by the ASTDD Best Practices Committee to identify and provide information on developing successful practices that address the oral health care needs of infants, toddlers and preschool children.
The ASTDD Best Practices Committee extends a special thank you to Centers for Disease Control and Prevention (CDC) for their partnership in the preparation of this report. Please visit the CDC Website at http://www.cdc.gov/oralhealth/ for more information.
This publication was supported by Cooperative Agreement U58DP001695 from CDC, Division of Oral Health and by Cooperative Agreement U44MC00177 from HRSA, Maternal and Child Health Bureau.
Suggested citation: Association of State and Territorial Dental Directors (ASTDD) Best Practices Committee. Best practice approach: school-based dental sealant programs [monograph on the Internet]. Sparks, NV: Association of State and Territorial Dental Directors; 2003 Jun 16. 12 p. Available from: http://www.astdd.org.
Attachment A: Strength of Evidence Supporting Best Practice Approaches