Dental Caries (Cavities): School-Based Dental Sealant Delivery Programs

The CPSTF finding is based on a systematic review of two types of evidence: evidence of effectiveness of programs that deliver sealants within school settings (4 studies; search period through October 2012), and evidence from one high quality systematic review of the efficacy of sealants among school-aged children (Ahovuo-Saloranta et al. 2013, search period 1946-2012; 34 included studies).

The systematic review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to oral health. This finding updates and replaces the 2000 CPST finding on School-Based or Linked Sealant Delivery Programs.

Information about data variability is available in the CPSTF Finding and Rationale Statement.

Programs that delivered sealants within school settings increased the proportion of students who received sealants and decreased occurrence of tooth decay.

• Implementing a sealant delivery program led to a 26 percentage point increase in the number of students who received sealants (2 studies). Greater increases were seen among students from low-income families.
• Students who received dental sealants had a median of 50% fewer cavities up to four years later as compared with students who did not receive sealants (interquartile interval [IQI]: 38% to 61%; 2 studies).

In the systematic review of sealant efficacy, dental sealants were shown to reduce dental caries by a median of 81% at 2 year follow up (IQI:74% to 88%; 12 studies).

Information about data variability is available in the CPSTF Finding and Rationale Statement.

Economic evidence indicates the benefits of school sealant programs exceed their costs when implemented in schools that have a large number of students at high risk for cavities.

The economic review included 14 studies 4 studies with information on resource costs from the original 2002 economic review and 10 studies identified for the current review (search period January 2000-December 2014). All monetary values reported are in 2014 U.S. dollars.

Intervention Cost

• Labor accounted for about two-thirds of the intervention cost per child in the included studies.
  

  Intervention Benefit

  Cost Effectiveness

  A comparison of the median intervention cost to seal a tooth and the 4-year economic benefit suggests school-based sealant delivery programs become cost-saving within 2 years.

  • Intervention costs were lower when sealants were applied in less time or when dental hygienists, rather than dentists, were used to determine whether sealants were appropriate for individual students.
    • The second-most expensive cost contributor was one-time, single-use consumable supplies associated with infection control (e.g., masks, gloves).
    • Costs for these supplies likely were lower for interventions that screened students and applied sealants at the same visit.
    • Medical claims data and economic models were used to estimate the cost of dental treatment averted as a result of sealant placement.
    • Economic models were used to estimate the cost of parents’ averted productivity losses.
    • Cost effectiveness studies were conducted from a societal or healthcare payers’ (Medicaid) perspective.
      • Societal perspective:
        • Three of four studies reported school-based sealant delivery programs were cost-saving or cost-neutral based on cost per averted caries or per caries free child, meaning the benefits either exceeded or matched the costs of the intervention.
      • Healthcare payers’ (Medicaid) perspective:
        • Two of three studies found that interventions were cost-saving when delivered in settings where the children were at high risk for caries.
        • When parents’ averted productivity losses were considered, three of the four estimates of net costs from the third study showed that the intervention was cost-saving or cost-neutral.
    • Estimates of averted caries were converted into disability adjusted life years and showed school-based sealant delivery programs were cost effective.

• Findings should be applicable to school-based, sealant delivery programs in communities throughout the U.S.
• Studies included in the review evaluated programs that used a variety of licensed dental professionals (e.g., dentists, dental hygienists, dental therapists) to place dental sealants. No evidence was found to suggest variation in longevity of sealants applied by different dental health professionals.

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

• The effect of school-based sealant delivery programs on racial or ethnic disparities in rates of dental cavities
• The use of school-based sealant delivery programs as part of multicomponent vs. single component programs
• The age at which sealants should be placed
• The need and timing for sealant maintenance
• The effectiveness of dental sealant application onsite and off-site
• The benefit of programs for children at moderate to low risk

Future studies should clearly describe methods by which schools are recruited and programs are implemented. Detailed information should be provided about the following:

• Who consents to participate and who does not
• Why people do or do not choose to participate
• The timing and quality of sealant information provided to schools and parents and the timing of parental consent

Finally, future research and evaluation should more clearly examine the costs and benefits of school-based dental sealant delivery programs. Specifically, research should address the following:

• To what extent dental fees and dental reimbursement rates adequately capture the actual resource costs to place sealants?
• What are the productivity losses associated with parents taking their child to a dentist for restorative care?
• What are the future productivity losses for students associated with missed school and lower academic performance attributable to untreated tooth decay?
• What are the specific costs of administering a school-based dental sealant delivery program, and how do they vary by area or setting?

• In most of the included studies, analyses focused only on children who consented to the sealant program, rather than those who were eligible to participate. It is possible that excluding those who did not consent excluded data from highest-risk children.
• The majority of evidence came from studies of children aged 5-10 years.
• Included evidence comes from studies conducted in the U.S. and Europe.
• All studies assessed sealants applied within the school setting, as opposed to off-site in dental clinics.
• Most of the data for effectiveness of school-based sealant delivery programs are from areas of middle to low socioeconomic status.

Griffin SO, Naavaal S, Scherrer C, Patel M, Chattopadhyay S, Community Preventive Services Task Force. Evaluation of school-based dental sealant programs: an updated Community Guide systematic economic review. American Journal of Preventive Medicine. 2017;52(3):407–415.

Griffin S, Naavaal S, Scherrer C, Griffin PM, Harris K, Chattopadhyay S. School-based dental sealant programs prevent cavities and are cost-effective. Health Affairs. 2016;35(12):2233-40. Available at: http://content.healthaffairs.org/content/35/12/2233.full.

Effectiveness Review

Analytic Framework

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

Summary Evidence Table – Effectiveness Review

Economic Review

Summary Evidence Table – Economic Review

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained n several publications).

Effectiveness Review

Bravo M, Baca P, Llodra JC, Osorio E. A 24-month study comparing sealant and fluoride varnish in caries reduction on different permanent first molar surfaces. J Public Health Dent 1997;57(3):184-6.

Bravo M, Llodra JC, Baca P, Osorio E. Effectiveness of visible light fissure sealant (Delton) versus fluoride varnish (Duraphat); 24-tnonth elinieal trial, Cotntnunity. Dent Oral Epidetniol 1996;24:42-6.

Bravo M, Montero J, Bravo JJ, Baca P, Llodra JC. Sealant and fluoride varnish in caries: a randomized trial. J Dent Res 2005;84(12):1138-43.

Klein SP, Bohannan HM, Bell RM, Disney JA, Foch CB, Graves RC. The cost and effectiveness of school-based preventive dental care. American Journal of Public Health 1985;75:382-91.

Siegal MD, Detty AMR. Do school-based dental sealant programs reach higher risk children? Journal of Public Health Dentistry 2010;70:181 7.

Siegal MD, Detty AMR. Targeting school-based dental sealant programs: who is at “higher risk?” Journal of Public Health Dentistry 2010;70:140 7.

Siegal MD, Miller DL, Moffat D, Kim S, Goodman P. Impact of targeted, school-based dental sealant programs in reducing racial and economic disparities in sealant prevalence among schoolchildren Ohio, 1998 1999. MMWR 2001;50(34):736-8.

Economic Review

Arrow P. Cost minimization analysis of two occlusal caries preventive programmes. Community Dental Health 2000;17:85-91.

Bertrand E, Mallis M, Bui NM, Reinharz D. Cost-effectiveness simulation of a universal publicly funded sealants application program. J Public Health Dent 2011;71(1):38-45

Bhuridej P, Kuthy RA, Flach SD, Heller KE, Dawson DV, Kanellis MJ, Damiano PC. Four-year cost-utility analyses of sealed and nonsealed first permanent molars in Iowa Medicaid-enrolled children. J Public Health Dent 2007 Fall;67(4):191-8.

Calderone JJ, Mueller LA. The cost of sealant application in a state dental disease prevention program. J Public Health Dent 1983;43:249 54.

Dasanayake AP, Li Y, Kirk K, Bronstein J, Childers NK. Restorative cost savings related to dental sealants in Alabama Medicaid children. Pediatr Dent 2003;25(6):572-6.

Garcia AI. Caries incidence and costs of prevention programs. J Public Health Dent 1989;49(5 spec no):259 71.

Griffin SO, Griffin PM, Gooch BF, Barker LK. Comparing the costs of three sealant delivery strategies. Journal of Dental Research 2002;81(9):641-5.

Klein SP, Bohannan HM, Bell RM, Disney JA, Foch CB, Graves RC. The cost and effectiveness of school-based preventive dental care. Am J Public Health 1985;75:382 91.

Mari o R, Fajardo J, Morgan M. Cost-effectiveness models for dental caries prevention programmes among Chilean schoolchildren. Community Dent Health 2012 Dec;29(4):302-8.

Morgan MV, Crowley SJ, Wright C. Economic evaluation of a pit and fissure dental sealant and fluoride mouthrinsing program in two nonfluoridated regions of Victoria, Australia. J Public Health Dent 1998;58:19 27.

Quinonez RB, Downs SM, Shugars D, Christensen J, Vann WF Jr. 2005 Spring;65(2):82-9. Assessing cost-effectiveness of sealant placement in children. J Public Health Dent 2005;65(2):82-9.

Scherrer CR, Griffin PM, Swann JL. Public health sealant delivery programs: optimal delivery and the cost of practice acts. Med Decis Making 2007c;27(6):762-71.

Weintraub JA, Stearns SC, Burt BA, Beltran E, Eklund SA. A retrospective analysis of the cost-effectiveness of dental sealants in a children’s health center. Soc Sci Med 1993;36(11):1483-93.

Weintraub JA, Stearns SC, Rozier G, et al. Treatment outcomes and costs of dental sealants among children enrolled in Medicaid. Am J Public Health 2001;91:1877-81.

Implementation Resources

Preventing Dental Caries Through School-Based Sealant Programs: Updated Recommendations and Review of Evidence
Published in the November 2009 issue of Journal of the American Dental Association, this article provides guidance for using school-based sealant programs. The recommendations were developed by a CDC work group of experts in cavity prevention and treatment, oral epidemiology, and evidence-based reviews, and representatives from professional dental organizations.

Rural Health Information Hub, Oral Health Toolkit
This toolkit compiles information, resources, and best practices to support development and implementation of oral health programs in rural communities. Modules include program models, implementation and evaluation resources, and funding and dissemination strategies.

• School-based Model

Four bibliographic databases were searched through October 2012: OHG Register, CENTRAL, MEDLINE, and EMBASE. The databases searched covered publications in biomedical and behavioral sciences. Search strategies were adjusted to each database, based on controlled and uncontrolled vocabularies and search software. The types of documents searched in the databases included journal articles, books, book chapters, reports, conference papers, and dissertations. In addition, the bibliographies of all reviewed articles were used to identify any further literature.

OHG Trial Register

“pit and fissure sealant*” OR pit-and-fissure-sealant* OR (fissure* AND seal*) OR “resin seal*” OR “dental seal*” OR “tooth seal*” OR “enamel seal*” OR ((“glass ionomer*” OR glass-ionomer* OR resin*) AND seal*)

AND

(caries or decay or deminerali* or reminerali* or carious or cavit* or (teeth and lesion*) or (tooth and lesion*) or (dental and lesion*)) AND (school* and (program* or campaign* or curricul* or train* or teach*))

CENTRAL

1. MeSH descriptor Tooth demineralization explode all trees
2. (caries in All Text or carious in All Text)
3. (teeth in All Text and (cavit* in All Text or caries in All Text or carious in All
   • Text or decay* in All Text or lesion* in All Text or deminerali* in All Text or reminerali* in All Text) )
4. (tooth in All Text and (cavit* in All Text or caries in All Text or carious in All
   • Text or decay* in All Text or lesion* in All Text or deminerali* in All Text or reminerali* in All Text) )
5. (dental in All Text and (cavit* in All Text or caries in All Text or carious in All
   • Text or decay* in All Text or lesion* in All Text or deminerali* in All Text or
   • reminerali* in All Text) )
6. (enamel in All Text and (cavit* in All Text or caries in All Text or carious in All
   • Text or decay* in All Text or lesion* in All Text or deminerali* in All Text or
   • reminerali* in All Text) )
7. (dentin in All Text and (cavit* in All Text or caries in All Text or carious in All
   • Text or decay* in All Text or lesion* in All Text or deminerali* in All Text or reminerali* in All Text) )
8. (root* in All Text and (cavit* in All Text or caries in All Text or carious in All Text or decay* in All Text or lesion* in All Text or deminerali* in All Text or reminerali* in All Text) )
9. MeSH descriptor Dental plaque this term only
10. ( (teeth in All Text or tooth in All Text or dental in All Text or enamel in All Text
    • or dentin in All Text) and plaque in All Text)
11. MeSH descriptor Dental health surveys explode all trees
12. (“DMF Index” in All Text or “Dental Plaque Index” in All Text)
13. (#1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11 or #12)
14. MeSH descriptor Pit and fissure sealants this term only
15. (fissure in All Text near/6 seal* in All Text)
16. (dental in All Text near/3 sealant* in All Text)
17. (resin* in All Text near/4 sealant* in All Text)
18. (compomer* in All Text near/4 sealant* in All Text)
19. (composite* in All Text near/4 sealant* in All Text)
20. MeSH descriptor Glass ionomer cements explode all trees
21. MeSH descriptor Resins, synthetic explode all trees
22. (“glass ionomer*” in All Text or glassionomer* in All Text or glass-ionomer* in
    • All Text)
23. (#20 or #21 or #22)
24. sealant* in All Text
25. (#23 and #24)
26. (#14 or #15 or #16 or #17 or #18 or #19 or #25)
27. (#13 and #26)
28. MeSH descriptor Schools this term only
29. ( (school in All Text near/5 program* in All Text) or (school in All Text near/5
    • campaign* in All Text) or (school in All Text near/5 train* in All Text) or (school* in All Text near/5 teach* in All Text) or (school in All Text near/5 curricul* in All Text) )
30. (#28 or #29)
31. (#13 and #30)
32. (#31 or #27)

MEDLINE via OVID

1. exp TOOTH DEMINERALIZATION/
2. (caries or carious).mp.
3. (teeth adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.
4. (tooth adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.
5. (dental adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.
6. (enamel adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.
7. (dentin$ adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.
8. (root$ adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.
9. Dental plaque/
10. ((teeth or tooth or dental or enamel or dentin) and plaque).mp.
11. exp DENTAL HEALTH SURVEYS/
12. (“DMF Index” or “Dental Plaque Index”).mp.
13. or/1-12
14. “Pit and Fissure Sealants”/
15. (fissure$ adj6 seal$).mp.
16. (dental adj3 sealant$).mp.
17. (resin$ adj4 sealant$).mp.
18. (compomer$ adj4 sealant$).mp.
19. (composite$ adj4 sealant$).mp.
20. exp Glass Ionomer Cements/
21. exp Resins, synthetic/
22. (“glass ionomer$” or glassionomer$ or glass-ionomer$).mp.
23. 20 or 21 or 22
24. sealant$.mp.
25. 23 and 24
26. 14 or 15 or 16 or 17 or 18 or 19 or 25
27. 13 and 26
28. Schools/
29. (school$ adj5 (program$ or campaign$ or curricul$ or train$ or teach$)).mp
30. 28 or 29
31. 30 and 13
32. 27 or 31
33. case reports.pt.
34. Comment/
35. Letter/
36. Editorial/
37. or/33-36
38. 32 not 37
39. exp animals/ not humans.sh.
40. 38 not 39

EMBASE via OVID

1. exp DENTAL CARIES/
2. (caries or carious).mp.
3. (teeth adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or
   • reminerali$)).mp.
4. (tooth adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or
   • reminerali$)).mp.
5. (dental adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.
6. (enamel adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or reminerali$)).mp.
7. (dentin$ adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$
   • or reminerali$)).mp.
8. (root$ adj5 (cavit$ or caries$ or carious or decay$ or lesion$ or deminerali$ or
   • reminerali$)).mp.
9. TOOTH PLAQUE/
10. ((teeth or tooth or dental or enamel or dentin) and plaque).mp.
11. (“DMF Index” or “Dental Plaque Index” or “Dental Health Survey$”).mp.
12. or/1-11
13. “Fissure Sealant”/
14. (fissure$ adj6 seal$).mp.
15. (dental adj3 sealant$).mp.
16. (resin$ adj4 sealant$).mp.
17. (compomer$ adj4 sealant$).mp.
18. (composite$ adj4 sealant$).mp.
19. Glass Ionomer/
20. exp Resins/
21. (“glass ionomer$” or glassionomer$ or glass-ionomer$).mp.
22. 19 or 20 or 21
23. sealant$.mp.
24. 22 and 23
25. 13 or 14 or 15 or 16 or 17 or 18 or 24
26. 12 and 25
27. School/
28. (school$ adj5 (program$ or campaign$ or curricul$ or train$ or teach$)).mp.
29. 27 or 28
30. 12 and 29
31. 30 or 26
32. exp animals/
33. exp human/
34. 33 not 32
35. 31 and 34

Ahovuo-Saloranta A, Forss H, Walsh T, Hiiri A, Nordblad A, M kel M, Worthington HV. (2013) Sealants for preventing dental decay in the permanent teeth. ‘Cochrane Database of Systematic Reviews 2013’, Issue 3. Art. No.: CD001830. DOI: 10.1002/14651858.CD001830.pub4

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.

• Sealant application demands meticulous technique. Licensed dental health professionals should consult the manufacturer’s instructions for use of specific sealant products.
• These programs can increase the identification of caries in children who do not regularly visit a dentist and improve access to dental health services by referring children who need dental treatment. They may also offer opportunities for children to receive additional preventive strategies.
• Educating parents, children, and teachers about the benefits of dental sealants may increase program acceptance.
• When individual children within a school are targeted for intervention, there may be an associated stigma (when compared with programs that target entire schools).
• Ideally, sealants should be applied as soon as possible after tooth eruption.
• Maintenance is encouraged, but a lack of resources or opportunities to maintain sealants should not prevent their use with high risk children. The evidence for the efficacy of sealants is predominantly based on trials with one-time sealant placement and no follow-up, suggesting a benefit even when sealants cannot be maintained.
• Sealant delivery programs can be an important way to reach children from low-income families who are at higher risk for caries and less likely to access clinical care.

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Increase the proportion of low-income youth who have a preventive dental visit — OH-09
• Increase the proportion of children and adolescents who have dental sealants on 1 or more molars — OH-10