Dental pit and fissure sealants: implications for school health personnel.
ABSTRACT: While tooth decay among schoolchildren has declined in recent years, 95% of all
schoolchildren still experience tooth decay. School-based fluoride rinse programs have made a
significant contribution to the decrease in tooth decay. Pit and fissure sealants, one other
preventive dentistry measure, also fight tooth decay. A pit and fissure sealant placed on the
chewing surfaces of permanent molars acts as a barrier and protects caries-prone areas of the
teeth. For sealants to be effective, it is important that school health educators, nurses, and
administrators have the dental health knowledge necessary to make informed decisions about
school-based dental sealant programs. Examples of successful programs are discussed. (J Sch Health
The U.S. Surgeon General's Healthy People report outlined 14 national health objectives directly related to oral health. Seven of the 14 objectives pertain to school-age children, and one recommends that by 1990 at least 65% of U.S. schoolchildren should be adept at personal oral hygiene practices and should receive other preventive dental services (dental sealants) in addition to fluoride.
To help attain this goal, school health educators, nurses, and administrators need to be well-informed about dental sealants, attitudes toward them, their cost-effectiveness, and the current status of school-based sealant programs.
PIT AND FISSURE SEALANTS
Development of Sealants
In 1955, Buonocore reported the superiority of bonding acrylic resins to acid-etched enamel. He predicted the potential benefits of the acid-etch technique for preventing caries in pits and fissures, and conducted the first clinical investigation of sealants.[3,4] Since that time, the bonding technique has been used widely.
A pit and fissure sealant is a clear or shaded plastic material applied to the chewing surface of permanent molars and premolars. The sealant acts as a barrier, protecting caries-prone areas of the teeth from plaque and acid. As premolars and molars develop, depressions and grooves form in the chewing surfaces of the enamel. Pits and fissures become perfect places for plaque-containing bacteria to accumulate as toothbrush bristles cannot reach into the difficult to keep clean grooves and depressions. A child may practice excellent oral hygiene, make regular dental visits, and receive optimal fluoride protection and a proper diet but still be vulnerable to decay on the chewing surfaces. Sealants placed over the pits and fissures decrease the risk of decay.
A combination of fluorides and sealants provides optimal caries protection. Fluoride protection can decrease decay on smooth surfaces, while sealants are highly effective in preventing pit and fissure caries. Studies have indicated community water fluoridation and other methods of fluoride delivery have contributed to a decrease in smooth surface caries in children and adolescents. The present pattern of dental caries related to pits and fissures must now be addressed.
Sealants are not meant to be applied on all teeth or used with all people. Experts at the 1983 Consensus Development Conference on dental sealants outlined a broad population who might benefit from sealants. The panel identified: 1) children with newly erupted teeth with pits and fissures; 2) children whose lifestyle, developmental or behavioral patterns, or lack of fluoride exposure put them at high risk for dental caries; 3) children with teeth that have pits and fissures that are anatomically susceptible to caries; and 4) other persons who desire sealant application and for whom sealant therapy is technically feasible.
In community-based programs where resources are scarce, the panel recommended implementing sealant programs in communities where the preventive effect will be optimal, and with consideration for prevalence of approximal caries, fluoridation status, and unique features of the population. The panel recommended establishing priorities on the basis of eruptive patterns, control of smooth surface caries through the use of fluorides, known population groups with special needs, and those without access to restorative dental care. The American Dental Association recommends sealants for all children, even those who receive topical applications of fluoride or who live in communities with fluoridated water.
A model for selective sealing presented by Branson and Enterman examines patient and tooth factors. Patient factors include age, oral hygiene, recall status, past caries experience, and diet. Tooth factors are sound (caries-free), questionably carious, and caries-active. The model may help dental health personnel make knowledgeable decisions about sealant use.
Effectiveness of Sealants
In the past 20 years, numerous studies[4,9-16] reported the effectiveness of sealing pits and fissures on both primary and permanent teeth. Favorable results were reported when sealant procedures were followed correctly and appropriately. Ripa reported 76% of all teeth sealed were completely covered after one year. Reports of retention rates of different sealant materials ranged from 88% to 97% after one year. Findings of Mertz-Fairhurst et al indicated from 84% complete retention at one year to 31% at seven years. After four years, Charbeneau and Dennison reported a 52.4% retention rate. Recently, Simonsen reported 56.7% complete retention 10 years after one single application of pit and fissure sealants.
Application of sealants has been shown to arrest the caries process.[18-21] A clinical study by Mertz-Fairhurst et al revealed sealants arrested caries with a high degree of efficacy. No studies have reported significant caries progression beneath intact sealants.
Cost-Analysis of Sealants
Once a decision to fund a caries prevention program has been made, the best way to spend available funds must be determined. Is dental education, fluoride mouthrinsing, sealants, or a combination of these methods the best and most cost-effective choice?
Sealant treatment costs include the initial application and, if necessary, replacement service. Direct expenses include material costs and the operator's salary; administration and staff time represent common indirect expenditures. Investigators have debated the cost of sealants and the cost-effectiveness of the procedure. Simonsen criticized studies of cost of sealants for only assessing direct expenditures.
Cost assessments of sealant programs in public health settings vary. In New Mexico, sealant costs for a dental disease prevention program totaled $1.59 per tooth and $7.41 per child. Hardison reported the direct cost for a one-time sealant application in a community health program in Tennessee as $1.20 per tooth and $8.02 per child. Sealant costs in these two programs were comparable and contained evidence of being cost-effective. In comparison, the cost of providing sealants in the first year of the National Preventive Dentistry Demonstration Project reached $22.82 per child. The cost per child in the Cincinnati Sealant Program was consistently reduced during the first three years and ranged from $31.28 to $23.32.
Public health preventive dentistry programs incur capital and operating costs. Salaries, travel, supplies, maintenance, and education materials represent operating costs. Differences in program type, size, setting, and staff salaries affect sealant program operating expenses. However, some experts attribute cost discrepancies to incomplete cost accounting and inadequate analyst training. Burt suggested analysts without formal economic training provided lower estimates while economists projected higher estimates.
A 1982 ADA survey of private practitioners and specialists revealed a wide range of fees for sealants. Average fees were $11.14 per tooth and $27.77 per quadrant. Burt suggested a sealant vs. amalgam comparison was legitimate in the context of private practice and that a decision should be based on selected teeth. Dennison and Straffon compared the lifespan of sealant and amalgam and the time for initial material application and maintenance. After four years of investigation, they reported sealants took 29% less time and were 100% effective.
In public programs where prevention is emphasized, a sealants vs. amalgams comparison is inappropriate since sealants are a primary prevention service and placement of amalgams denotes treatment. Horowitz[30,31] estimated the cost of sealants was relatively high compared to the costs of other preventive methods, but concluded sealants would be cost-effective and a worthwhile contribution to preventive dentistry if sealant placement procedures were carried out by dental health auxiliaries.
Cost-effectiveness analysis attempts to determine the least expensive way of reaching a stated outcome. The sealant procedure becomes more cost-effective when the patient is caries-prone and fissure caries might be expected. Simonsen suggested it was not cost-effective to seal every caries-susceptible surface. Leverett et al reported that selective placement of sealants on teeth with incipient caries can improve the cost-effectiveness of the procedure.
Houpt and Shey outlined six variables that should be examined to determine the cost-effectiveness of pit and fissure sealants. Essential variables include caries prevalence, longevity of material, number of teeth being treated, time for the procedure, type of operator, and equipment cost. The model developed by Branson and Enterman may assist dental health personnel determine the cost-effectiveness of pit and fissure sealants.
The value of preventive care is the critical issue. Simonsen maintained the value of preventive care is determined by the individual or community. With the decline of caries in the United States due mainly to extensive and regular use of fluoride, the value of using sealants to reduce caries to a negligible level must be determined.
Attitudes Toward Sealants
Support for preventive use of sealants has come from professional organizations such as the American School Health Association, American Academy of Pediatric Dentistry, American Dental Hygienist Association, American Dental Association, American Association of Public Health Dentistry, American Public Health Association, and Association of State and Territorial Dental Directors.
At the 1983 NIH Health Consensus Development Conference, experts concluded the placement of sealants was a safe, underused, and effective measure to prevent pit and fissure caries. The panel recommended expanding the use of sealants to reduce the incidences of dental caries beyond those populations already exposed to fluorides and other treatments. The panel maintained such treatments would reduce expenditures for treatment and improve health. Despite this support, pit and fissure sealants are not being used optimally.
In a 1974 ADA survey of 3,225 dentists, reasons cited for not using sealants regularly included sealants do not last, they are not effective, and they are too expensive, the possibility of inadvertently sealing in decay, and unfamiliarity with sealant techniques. O'Riordan, in his study of 4,000 dentists, reported practitioners were concerned about the efficacy of sealant use as well as the possibility of long-range problems caused by sealing in decay. Twelve years after the 1974 ADA survey, Gift and Frew surveyed 3,000 dentists about the use of sealants. Results indicated an increase in, and a more positive attitude toward, sealant use. The findings of Rubenstein and Dinuis correlated reported use of sealants and graduation date. More recent dental school graduates were more in favor of sealants than those graduating in the 1970s. Considering the potential value of sealants, the investigators concluded the sealant acceptance rate to be very low.
The dental profession has yet to promote sealants with the same enthusiasm it advocated fluoride mouthrinses in schools, community water fluoridation, and regular oral prophylaxis and examination. In the early 1980s, 62 pedodontists were surveyed on why they were not using sealants. The four most frequent replies were: a class I amalgam is simpler, more economical, and more reliable; insurance companies will not cover cost of sealants; more longitudinal research is needed to determine efficacy; and too much bother to sell/explain to patient/parents. In contrast, longitudinal research has revealed amalgams are not necessarily simpler, cheaper, or more reliable. Lack of motivation to discuss and to sell the procedure may reveal a major problem concerning attitudes that impede implementation of new preventive dentistry methods. O'Neill reported practitioners were not incorporating information from dental research into their dental practices.
An uninformed public cannot create a demand for this preventive procedure. In 1984, almost 15 years after the first provisional acceptance of pit and fissure sealants by the ADA, Frazier acknowledged consumers' lack of awareness of the availability and efficacy of sealants. However, patient demand may influence dentists to use sealants. Graves noted that a wellness-oriented public may influence a profession to adopt new technologies.
Meanwhile, health professionals in private and public practices hold key positions to educate the public about the value of sealants. At the 10 sites of the National Preventive Dentistry Demonstration Program, the general level of acceptance and use of sealants rose as indicated by an increase in the number of sealants observed among children in nonsealant regimens during annual examinations.
SCHOOL-BASED DENTAL HEALTH PROGRAMS
Schools can influence a child's oral health. A school dental health program can help children understand the importance of proper oral hygiene and reinforce positive attitudes and practices toward dental health. Dental health should be integrated into all applicable aspects of health education. A coordinated dental health education and services program should: 1) encourage and motivate pupils to visit a dentist regularly for examination and treatment; 2) present scientifically accurate information about teeth and gums so pupils may learn how to care for their teeth and learn what the community does to promote dental health; 3) help to arrange dental care for pupils whose families have not been able to provide it; and 4) provide experiences, including food services, that encourage desirable dental health practices.
Many school-based dental health education programs have been successful. Program evaluations have consisted of assessments of the number of decayed, missing, and filled teeth, utilization of dental health services, and changes in dental health knowledge, attitudes, and practices. Preventive programs have focused on fluoride mouthrinses, flouride tablets, operator applied topical fluoride, school water fluoridation, prophylaxes, and dental health education, but few offered school-based dental sealant programs. Most programs offering sealants have been community-based.[45,46]
Public health administrators in Tennessee have adopted a progressive preventive philosophy for their dental health programs that calls for combining all available preventive measures to obtain optimal dental benefits. Pit-and-fissure sealant are included in their total preventive effort. Likewise, the Massachusetts Dept. of Public Health developed a sealant program that contained a school-based component. The program increased knowledge of sealants and sealant use among consumers. New Mexico also developed a similar program.
Since 1984, St. Paul, Minn., has operated a successful school-based sealant program. Private foundation grant monies, with local corporate and school board support, fund the program. Salaries for four full-time dental hygienists are paid by the school board under the school health program budget. The program was initiated in urban schools after surveys determined an increase in caries' incidence and that no preventive dental programs existed. Originally, the program was part of the dental preventive effort teamed with fluoride rinsing and dental health education. Currently, it is combined with fluoride mouthrinsing only and provides sealants to eligible second and fifth grade students.
The Cincinnati Sealant Program represents another noteworthy sealant program. Initiated as a demonstration project to determine the feasibility of starting sealant programs in other areas of Ohio, the program provides sealants to about 3,000 individuals each year. The program receives donations from three local agencies as well as a state grant. Since 1984, the program has increased the number of children examined and sealed, and the number of sealants applied. While the scope of the program has increased, the cost has continually decreased.
The number of children eligible for sealants is greater in school-based programs than in local health departments. Fluoride mouthrinse programs have successfully reduced caries rates in school-age children partly because schools provide excellent access to a large number of children. Advantages of a school-based pit and fissure sealant program include: 1) accessibility to eligible sealant applicants; 2) integration with and reinforcement of dental health education; and 3) introduction of dental health care to children in a friendly, non-threatening way. Furthermore, school-based sealant programs may increase the oral health status of the community and decrease school absenteeism due to dental problems.
The Michigan Dept. of Public Health developed a manual to assist local health departments and agencies to plan, implement, and conduct dental sealant programs in school settings. Out-of-state readers can review the planning guide upon request.
While use of fluoridated water, toothpastes, rinses, and tablets contributed to a significant decline in smooth surface caries among children and youth, a less positive impact has been made on caries affecting occlusal or pit and fissure surfaces. Sealant application to prevent caries is an underutilized procedure, but a justifiable one given the likelihood of further caries reduction. Implementation of school-based caries prevention programs, including the utilization of sealants, seems most appropriate and justifiable in small, nonfluoridated communities, particularly those with a large number of children and youth from low-income families who have minimal access to preventive or restorative dental care.
Several administrative barriers contribute to the low level of school-based sealant application programs. Administrators have concerns about the nature and efficacy of the preventive technology, the expense of maintaining a sealant program, and the fear implementation of such a program may disrupt planned educational processes and experiences, and alienate some parents.
Solutions to overcome these obstacles can be taken from the successes of school-based fluoridation programs. Superintendents, principals, school board members, and representatives of parents' groups must clearly understand the purpose of sealant application. School health education and services personnel, with assistance from dentists and dental hygienists, can facilitate this process. In one study, 83% of superintendents whose schools adopted self-application fluoride rinse programs reported school health personnel positively influenced the adoption process. School health team members were able to clarify administrators' misconceptions. A similar administrative staff education program would prove equally important. Temporal matters and cost-effectiveness concerns addressed previously[29-31] should further comprise any presentation to school administrators.
School health personnel must assume leadership roles that provide high visibility among persons who support prevention ideals and who can help influence school health policy decisions. Adoption and long-term maintenance of a school-based sealant application program may depend on the successfulness of school health personnel to inform and educate administrators and other policymakers.
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Public Health Service: The Prevention of Dental Caries in US Children, 1979-80: The National Dental Caries Prevention Survey. Washington, DC, US Government Printing Office, National Institutes of Health publication no 82-2245, 1981. McCormack KR, McDermott RJ: Selected factors affecting the caries status of youth: Implications for dental hygiene practice. Dent Hyg 1988;62(8):389-395. Coombs JA, Silversin JB, Drolette ME, Bikofsky CG, et al: A national study of fluoride mouthrinse adoption: Implications for school health personnel. J Sch Health 1983;53(1):39-44.
Kelli R. McCormack-Brown, PhD, RDH, Assistant Professor, Dept. of Health Sciences, Western Illinois University; and Barbara J. Clark, BS, RDH, Graduate Student; and Robert J. McDermott, PhD, FASHA, Associate Professor and Coordinator, Health Education Program, Dept. of Community and Family Health, College of Public Health, University of South Florida.
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|Author:||McCormack-Brown, Kelli R.; Clark, Barbara J.; McDermott, Robert J.|
|Publication:||Journal of School Health|
|Date:||Feb 1, 1989|
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