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  • 1. THE GUIDE TO COMMUNITY PREVENTIVE SERVICES: Effectiveness of school-based or school-linked pit and fissure sealant delivery programs and statewide or community-wide sealant programs in preventing dental caries Evidence Summary Table These tables present summary information about the studies included in the review of evidence for specific interventions. Data is presented for each study including author, study setting and/or population, sample size and results (i.e. effect change). The Guide to Community Preventive Services (Community Guide) provides recommendations on population-based interventions to promote health and to prevent disease, injury disability, and premature death, appropriate for use by communities and healthcare systems. For more information about the munity Guide (including links to publications and a variety of resources) see www.thecommunityguide.org for Oral Health see www.thecommunityguide.org/oral/ This information is in the public domain. Copyin and disseminating freely is encouraged. However, citation to source is appreciated. Created – July 1, 2002 page 1 of 11
  • 2. Summary Evidence Tables: Oral Health Studiesa measuring the effectiveness of school-based or school-linked pit and fissure sealant delivery programs and statewide or community-wide sealant programs in preventing dental caries Study location Outcomes and Effect Measures, Design suitability: Interventions studied, Comparisons Author, Year Setting (Sealant delivery including percentage point change Design (Number of participants) Study period mode) unless otherwise noted Quality of execution [Follow-up period] Population description (Statistical significance) Bagramian, Greatest: randomized Ypsilanti and Willow Run, MI 1. I1: bis-GMA sealant (Nuva-Seal; UV light Outcome: caries (DMFT and DMFS*) ; 19821 trial (child level) (USA) cured) + prophylaxis + fluoride gel (1.23%) + Effect Measures: needed restorations (n = 600 children (1973–1978) Fair 18 schools (School-based; randomized; 537, 491, 456, 174 analyzed at % reduction in mean occlusal caries increment mobile equipment) 1, 2, 3 & 5 yrs follow-up) vs (due to sealant + 6-month preventive regime), Recipients: grades 1 and 6 1 vs 3: 2. I2: bis-GMA sealant, etc (same as #1 for 3 (age 6 & 11 yrs), low-middle years then prophylaxis, fluoride gel, and free Year 1: overall = 84% (grade 1 = 88.3%; grade SES, 30% nonwhite restorations omitted for remaining 2 yrs; 6 = 79.2%) Operators: dentists & group I2 was formed by splitting the original intervention group into I1 and I2 after 3 years Year 2: (grade 1 = 74.3%; grade 6 = 77.1%) assistants (n = 159 after year 3) Year 3: (grade 1 = 72.8%; grade 6 = 72.9%) Water fluoridation: 1.0ppm 3. Control: No sealant, no prophylaxis, no (p<0.01; t-test for all comparisons); topical fluoride, no restorations (parents Year 5: (grade 1 = 45.5%; grade 6 = 30.4%) notified if fillings needed) (n = 600 (p<0.05) randomized; 546, 502, 462, 329 analyzed at 1, 2, 3 & 5 yrs follow-up) % reduction in mean occlusal caries increment (due to sealant + 6-month preventive regime [Follow-up every 6 months (intervention) and for 3 years), 2 vs 3: year (all groups) for 5 years] Year 5: (grade 1 = 64.6%; grade 6 = 27.3%) Note: School-based program: sealants applied to sound unsealed molars & premolars; re- (p<.01; t-test for all comparisons?) applied at 6 months, if lost. Both groups also Note: Low sealant retention at year 2: 10–67% received fluoridated drinking water, oral hygiene classes, daily supervised brushing & flossing (32 weeks per yr), dietary counseling, and dental exams including posterior bitewing radiographs annually. Groups 1 & 3 received dental visits every 6 months (prophy, gel, sealant, and fillings) page 2 of 11
  • 3. Summary Evidence Tables: Oral Health Studiesa measuring the effectiveness of school-based or school-linked pit and fissure sealant delivery programs and statewide or community-wide sealant programs in preventing dental caries Study location Outcomes and Effect Measures, Design suitability: Interventions studied, Comparisons Author, Year Setting (Sealant delivery including percentage point change Design (Number of participants) Study period mode) unless otherwise noted Quality of execution [Follow-up period] Population description (Statistical significance) Bravo, 19972 Greatest: randomized Granada, Spain 1. bis-GMA sealant (Delton—light cured; Outcome: caries (DMFT and DMFS) trial (classroom & child opaque)(n=5 classes) Analysis A: 75 (1990–1994) 5 schools (School-based; Effect measures: level) children, 238 molars (fully erupted at mobile equipment) baseline); analysis B: 100 children, number of A: % effectiveness* in reducing occlusal caries Good Recipients: age 6–8 yrs fissured and non-fissured surfaces not (DMF) after 2 yrs, 1 vs 3 = 76.8% (p<.001) (mean 7.45), 50% male, mid reported (fully erupted anytime in 24 months); analysis C: 104 children, 365 molars (fully 1 vs 2 = 62.7% (p<.001) to lower SES erupted anytime in 48 months) B: % reduction in DMFS increment after 2 yrs, Operators: dentist & assistants 2. Fluoride varnish (Duraphat) (n=5 classes) 1 vs 3: fissured surfaces= 67.6% (p<.001); Analysis A: 77 children, 252 molars (fully non-fissured surfaces=86.6% (p<.001) Water fluoridation = 0.07ppm erupted at baseline); analysis B: 98 children, number of fissured and non-fissured 1 vs 2: fissured surfaces= 48.0% (p<.001); surfaces not reported (fully erupted anytime non-fissured surfaces=60.8% (NS; p=.149) in 24 months); analysis C: 112 children, 402 C1:hazard ratio for molar failure (DMF) after 4 molars (fully erupted anytime in 48 months) yrs, 3. No sealant, no varnish (n=5 classes) 1 vs 3 = 0.18 (95% CI=0.12, 0.27) Analysis A: 94 children, 272 molars (fully erupted at baseline); analysis B: 116 1 vs 2 = 0.38 (95% CI not reported) children, number of fissured and non- C2: % effectiveness* in reducing risk of molar fissured surfaces not reported (fully erupted failure after 4 yrs, anytime in 24 months); analysis C: 128 children, 434 molars (fully erupted anytime 1 vs 3 = 82% in 48 months) 1 vs 2 = 62% [Follow-up every 6 months to 24 and 48 months] * Note:% effectiveness = (1–RR) x100 or Note: School-based program: sealant (or (1–HR) x100 varnish) applied to all erupted sound permanent 1st molars; re-applied after 6, 12, 18 months, if sealant lost or newly-erupted molar. No comparison group previously exposed to sealant, or other preventive service (supervised brushing, fluoride, etc.) at baseline page 3 of 11
  • 4. Summary Evidence Tables: Oral Health Studiesa measuring the effectiveness of school-based or school-linked pit and fissure sealant delivery programs and statewide or community-wide sealant programs in preventing dental caries Study location Outcomes and Effect Measures, Design suitability: Interventions studied, Comparisons Author, Year Setting (Sealant delivery including percentage point change Design (Number of participants) Study period mode) unless otherwise noted Quality of execution [Follow-up period] Population description (Statistical significance) Burt, 19773 Greatest: randomized London, England (UK) 1. bis-GMA sealant (Nuva-Seal) (n = 205 % effectiveness of sealant at 2 years: trial (child level) children at baseline; 118 children & 234 teeth (1973–1976) Schools (number not 1 vs 2 = 13.6% (NS; p<0.4) at 2 yrs) Fair reported) (School-linked; fixed equipment in health center) 2. No sealant (n = 205 children at baseline; 118 children & 234 contralateral teeth at 2 yrs) Recipients: age 5–12 yrs; low income [Follow-up at 6 months and 2 years] Operators: school dentists & Note: School-linked program: sealant applied assistants once to sound permanent teeth (premolars & molars) Water fluoridation = 0.2–0.3ppm Horowitz, 19774 Greatest: randomized Kalispell, Montana (USA) 1. bis-GMA sealant (UV light cured) (n=429 half- % reduction in occlusal caries (DMF) at 5 trial (child level; half- mouths at baseline, 241 [302 pairs of years: (1970–1975) Schools (School-based; mouth) teeth–premolars & molars] at 5 yr follow-up) portable equipment) 1 vs 2 = 35% (significance test not reported) Fair 2. No sealant (n=same as in 1) Recipients: age 5–8 and 38% (age 10–14 yrs) and 30% (age 5–8 yrs) 10–14 yrs; unknown SES [Follow-up annually for 5 years] Operators: dentists Note: School-based program: sealant applied once to sound permanent premolars and molars Water fluoridation = negligible page 4 of 11
  • 5. Summary Evidence Tables: Oral Health Studiesa measuring the effectiveness of school-based or school-linked pit and fissure sealant delivery programs and statewide or community-wide sealant programs in preventing dental caries Study location Outcomes and Effect Measures, Design suitability: Interventions studied, Comparisons Author, Year Setting (Sealant delivery including percentage point change Design (Number of participants) Study period mode) unless otherwise noted Quality of execution [Follow-up period] Population description (Statistical significance) Klein, 19855 Greatest: non- 10 communities (USA): 1. bis-GMA sealant (Nuva-Seal) + prophylaxis % of occlusal decay prevented by sealant randomized trial (+fluoride gel--1.23%) vs (longitudinal cohort) at 4 years, (1+2+3A) vs (1979–1983) 5 nonfluoridated (Billerica MA; (3B+4+5+6): Good Tallahassee, FL; Wichita, KS; 2. bis-GMA sealant + prophy/gel + rinse Monroe, LA; Pierce County, (tablets) + lessons + brushing vs fluoridated (grades 1 & 2) = 23% WA) 3. A) bis-GMA sealant + rinse + lessons + fluoridated (grade 5) = 65% (p<.0.001) 5 fluoridated (Chattanooga, brushing (fluoridated sites only) vs Mean reduction in DMFS increments due to TN; New York, NY; B) Rinse + tablets + lessons + brushing + sealants at 4 years (longitudinal cohort), Minneapolis, MN; El Paso, prophy/gel (nonfluoridated sites only) vs (1+2+3A) vs (3B+4+5+6): TX; Hayward, CA [intermittent fluoridation] ) 4. Rinse (tablets) + lessons + brushing nonfluoridated (grades 1& 2) = 1.33 (p<.001) In schools (School-based; 5. Lessons + brushing nonfluoridated (grade 5) = 1.11 (p<.05); mobile equipment) 6. None of the above fluoridated (grades 1 & 2) = 0.96 (p<.001); Recipients: grades 1, 2 & 5, percentage nonwhite not [Follow-up every year for 4 years; 3 years in NY] fluoridated (grade 5) = 2.00 (p<.001) reported Note: School-based program: sealants (to Note: Effects of sealant estimated by Operators: hygienists & unsealed molars & premolars) and prophy/gel comparing cohorts 1, 2 & 3A with cohorts 3B, 4 assistants supervised by were applied in mobile clinic; mouthrinse, tablets, & 5 that did not receive sealants. Six treatment dentist; classroom teachers & and health lessons were supervised by regimens (5 intervention and 1 control) were aides classroom teachers. Lost sealants were re- applied to each of 4 cohorts: Baseline: grades applied every 6 months x 3; needed fillings 1+2 (fluoridated = 6847; nonfluoridated = Water fluoridation: variable (parents notified of need for restorations). Both 6900); grade 5 (fluoridated = 3186; groups also received fluoridated drinking water, nonfluoridated = 3119). Follow-up (4 years): oral hygiene classes, daily supervised brushing grades 1+2 (fluoridated = 2777; nonfluoridated & flossing (32 weeks per yr), dietary counseling, = 3960); grade 5 (fluoridated = 1141; non- and dental exams including posterior bitewing fluoridated = 1688) radiographs annually page 5 of 11
  • 6. Summary Evidence Tables: Oral Health Studiesa measuring the effectiveness of school-based or school-linked pit and fissure sealant delivery programs and statewide or community-wide sealant programs in preventing dental caries Study location Outcomes and Effect Measures, Design suitability: Interventions studied, Comparisons Author, Year Setting (Sealant delivery including percentage point change Design (Number of participants) Study period mode) unless otherwise noted Quality of execution [Follow-up period] Population description (Statistical significance) McCune, 19796 Greatest : non- Medellin, Colombia 1. bis-GMA sealant (?Delton, chemically cured) % reduction in incident caries, 1 vs 2: randomized trial (n=200 children, 318 molars at baseline; 170 (1976–1979) Number of schools not 92.5% (Significance test not reported) at 2 yr children, 272 molars at 30-year follow-up) Fair reported; (School-linked) 84.7% at 3 yr follow-up 2. No sealant (same child, same jaw, Recipients: age 6–8 years contralateral tooth) (n= same as in 1) Operators: dentists [Follow-up at 6, 12, 24, 36 months] Water fluoridation: (fluoride Note: School-linked program: sealant applied concentration not reported) once to caries-free permanent first molars Messer, 19977 Least: retrospective Melbourne, Australia 1. bis-GMA sealant (Conseal) (n= 774 children Outcome: DMFS per Radike criteria cohort in all 3 comparison groups; 2982 completely (1989–1994) 15 schools (School-linked) Effect measure: retained sealants on teeth sealed once Fair Recipients: age 6–12 yrs; between 1989 and 1994) Difference in % of sealed surfaces with 51% female restored or unrestored caries at 2 yrs, 1 vs 3: 2. bis-GMA sealant (Conseal) (number of Operator: dental therapists children not reported; 1539 partially retained 14% (15% – 1%); (p value not significant) sealants on teeth sealed once between 1989 Water fluoridation: fluoride and 1994) Difference in % of sealed surfaces with concentration not reported restored or unrestored caries at 2 yrs, 2 vs 3: 3. bis-GMA sealant (Conseal) (number of children not reported; 842 missing sealants 5% (15% – 10%); (p value not significant) on teeth sealed once between 1989 and 1994) Note: School-linked program: historical cohort (sealant applied to permanent molars, premolars, and lateral incisors between 1989 and 1994) examined for sealant retention and caries in 1994 page 6 of 11
  • 7. Summary Evidence Tables: Oral Health Studiesa measuring the effectiveness of school-based or school-linked pit and fissure sealant delivery programs and statewide or community-wide sealant programs in preventing dental caries Study location Outcomes and Effect Measures, Design suitability: Interventions studied, Comparisons Author, Year Setting (Sealant delivery including percentage point change Design (Number of participants) Study period mode) unless otherwise noted Quality of execution [Follow-up period] Population description (Statistical significance) Selwitz, 19958 Least: before-and-after Nelson County, VA (USA) 1. bis-GMA sealant (Concise: opaque, self- % reduction in mean occlusal DMFS at 4 yrs 1 cured) + fluoride rinse (0.2% sodium flouride vs 2: (1983–1987) Fair 8 schools (School-based; weekly) + fluoride tablet (2.2mg sodium mobile equipment) Ages 7-11 yrs = 78% (95% CI=46%, 93%) flouride daily) + oral hygiene education (n = Recipients: 6–13 years 416 children at 4-year follow-up) Ages 14-17 yrs = 23.7% (95% CI= 8%, 169% [adjusted for secular trend using incident Operators: dentists, 2. No sealant (historical control before 1983) + approximal caries rate] ) hygienists, assistants fluoride rinse (0.2% sodium fluoride weekly) + fluoride tablet (2.2mg sodium fluoride daily) + Water fluoridation: fluoride oral hygiene education (n = same as in 1) concentration not reported [Baseline and follow-up exams in 1983 and 1987] Note: School-based program: sealant applied once to permanent lateral incisors, premolars & molars, sufficiently erupted with no approximal decay (between adjacent teeth); successive cohorts of children screened for eligibility and treated in Feb and Oct each year page 7 of 11
  • 8. Summary Evidence Tables: Oral Health Studiesa measuring the effectiveness of school-based or school-linked pit and fissure sealant delivery programs and statewide or community-wide sealant programs in preventing dental caries Study location Outcomes and Effect Measures, Design suitability: Interventions studied, Comparisons Author, Year Setting (Sealant delivery including percentage point change Design (Number of participants) Study period mode) unless otherwise noted Quality of execution [Follow-up period] Population description (Statistical significance) Songpaissan, Greatest: non- Bangkok, Thailand 1. bis-GMA sealant (Delton, self-curing, by % reduction in occlusal caries at 2 yrs: 19959 randomized trial dentist) (n=143) (age 12-13 yrs only) 4 schools (School-based and - Ages 7-8 yrs: GIC-sealant (by dentist), 2 vs 5 = (1991–1993?; Fair linked; mobile equipment or 2. GIC sealant by dentist (n=239) 52% (p<0.05; one-way ANOVA, Scheffe’s exact dates health center clinic) test); GIC sealant (by teacher), 3 vs 5 = 74% 3. GIC sealant by trained (3 days) teacher unclear from (p<0.05) Recipients: age 7–8 & 12–13 (n=243) report) yrs, very low–middle SES, Ages 12-13 yrs: bis-GMA sealant (by dentist), 4. Topical fluoride (HF) by dentist (n=234) 51% female 1 vs 5 = 93% (p<0.05); GIC-sealant (by 5. No sealant nor topical fluoride (from dentist) 31% (NS); GIC-sealant (by teacher) = Operators: dentist & trained researchers) (n=261) 20% (NS) teachers (Total children enrolled & completing study = Water fluoridation: 1264 and 1110; analysis samples shown above) 0.1–0.2ppm (natural) [Follow-up at 6, 12, 18, 24 months] Note: Baseline DFS was equal in comparison groups Note: School-based and school-linked programs: sealants (school-linked) applied to permanent molars at baseline and re-applied at 6 months if needed. HF applied by dentist at baseline, 6 & 12 months; exam for caries and sealant retention by dentist page 8 of 11
  • 9. Summary Evidence Tables: Oral Health Studiesa measuring the effectiveness of school-based or school-linked pit and fissure sealant delivery programs and statewide or community-wide sealant programs in preventing dental caries Study location Outcomes and Effect Measures, Design suitability: Interventions studied, Comparisons Author, Year Setting (Sealant delivery including percentage point change Design (Number of participants) Study period mode) unless otherwise noted Quality of execution [Follow-up period] Population description (Statistical significance) Sterritt, 199410 Moderate: time series (5 Guam, USA Territory 1. bis-GMA sealant (Delton) (1984-1989) + % reduction of occlusal caries (mean DMFS before-and-after cross- fluoride mouth rinse (FMR) (1976-1989) (n = per child) due to Sealant + FMR + CWF, after (1976–1989) 46 schools (School-linked; sectional measures) see below) 5 years (1984-1989), 2 vs 3: 69.7% (p value fixed equipment at public not reported) Fair health dental clinics) 2. bis-GMA sealant (Delton) (1984-1989) + fluoride mouth rinse (FMR) (1976-1989) + Sealant + FMR, after 2 years (1984-1986), 1 Recipients: grades 1–8, age community water fluoridation (1986-1989) vs 3: 54.6% (p value not reported) 6–14 yrs 3. No sealant, FMR alone (1976-1984) FMR alone, after 8 years (1976-1984), before Operators: dentists & vs after = 7% (p value not reported) auxiliaries (expanded N= 15,000 children (75,000 teeth per year) function) received sealants in 1984-1986. Analysis samples included 994, 1045, 1061, 987, 946 Water fluoridation: fluoride children, in 1976, 1979, 1984, 1986, 1989, concentration not reported respectively) (1986–1989) [Follow-up = time series measures of sealant Note: Mean DMFS, age 6–14 and caries status using 5 cross-sectional surveys yrs = 5.35 in 1984 (multistage, stratified, probability samples of 46- school frame)] Note: School-linked program: sealants applied to occlusal surfaces of permanent teeth (all molars & selected premolars or incisors) without undermining caries or restorations duiring 1-2 visits to clinics by bus. Lost sealants were re- applied annually as needed. All comparison groups (historical controls) also received oral hygiene education, including toothbrushing instruction page 9 of 11
  • 10. Summary Evidence Tables: Oral Health Studiesa measuring the effectiveness of school-based or school-linked pit and fissure sealant delivery programs and statewide or community-wide sealant programs in preventing dental caries Study location Outcomes and Effect Measures, Design suitability: Interventions studied, Comparisons Author, Year Setting (Sealant delivery including percentage point change Design (Number of participants) Study period mode) unless otherwise noted Quality of execution [Follow-up period] Population description (Statistical significance) Siegal, 199611 Least: before-and-after Ohio, USA 1. Public education campaign (public service Outcome: % of dentists who reported using announcements [PSAs], news releases, sealants (1989–1992) Fair DOH-sponsored statewide billboards) + professional education educational campaign to Effect Measures: campaign (journal articles, continuing promote appropriate sealant education, brochures, posters, patient % increase in dentists who reported using use education videos) + increased support for sealants after 2 yrs, 1 vs 2 = 12.4% (79.4% in Target populations included school-based sealant delivery programs 1989) and (91.8% in 1992) (p<0.0001) dentists, schools, and the (n=analysis samples of surveys: 335 dentists, 61% response rate [RR] in 1989; and 378 Note: Authors did not attribute increase in public dentists, 74% RR in 1992) reported sealant use to educational campaign because of inability to rule out secular trend 2. No campaign (historical control before 1989) and other unmeasured factors as causes of the changes in the outcome of interest [Before and after surveys in 1989 and 1992] Note: Effect of campaign on self-reported use of sealants by dentists ascertained by baseline and follow-up surveys of licensed general dentists in Ohio (N=5,000 - 6,000) bis–GMA, bisphenol-A-glycidyl methacrylate; CI, confidence interval; CWF, community water fluoridation; D(d), decayed; M(m), missing; F(f), filled, S(s), surface; T(t), tooth : uppercase and lowercase letters indicate permanent and primary teeth, respectively; DOH, department of health; FMR, flouride mouth rinse; GIC, glass ionomer cement; HF, hydrofluoric acid solution; HR, hazard ratio from Cox model; NS, not significant; RR, relative risk from logistic regression model; SES, socioeconomic status References 1. Bagramian RA. A 5-year school-based comprehensive preventive program in Michigan, U.S.A. Community Dentistry & Oral Epidemiology 1982;10:234-7. 2. 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. Journal of Public Health Dentistry 1997;57:184-6. page 10 of 11
  • 11. 3. Burt BA, Berman DS, Silverstone LM. Sealant retention and effects on occlusal caries after 2 years in a public program. Community Dentistry & Oral Epidemiology 1977;5:15-21. 4. Horowitz HS, Heifetz SB, Poulsen S. Retention and effectiveness of a single application of an adhesive sealant in preventing occlusal caries: final report after five years of a study in Kalispell, Montana. Journal of the American Dental Association 1977;95:1133-9. 5. 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. 6. McCune RJ, Bojanini J, Abodeely RA. Effectiveness of a pit and fissure sealant in the prevention of caries: three-year clinical results. Journal of the American Dental Association 1979;99:619-23. 7. Messer LB, Calache H, Morgan MV. The retention of pit and fissure sealants placed in primary school children by Dental Health Services, Victoria. Australian Dental Journal 1997;42:233-9. 8. Selwitz RH, Nowjack-Raymer R, Driscoll WS, Li SH. Evaluation after 4 years of the combined use of fluoride and dental sealants. Community Dentistry & Oral Epidemiology 1995;23:30-5. 9. Songpaisan Y, Bratthall D, Phantumvanit P, Somridhivej Y. Effects of glass ionomer cement, resin-based pit and fissure sealant and HF applications on occlusal caries in a developing country field trial. Community Dentistry & Oral Epidemiology 1995;23:25-9. 10. Sterritt GR, Frew RA, Rozier RG. Evaluation of Guamanian dental caries preventive programs after 13 years. Journal of Public Health Dentistry 1994;54:153-9. 11. Siegal MD, Garcia AI, Kandray DP, Giljahn LK. The use of dental sealants by Ohio dentists. Journal of Public Health Dentistry 1996;56:12-21. page 11 of 11