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  • Good morning. It’s my pleasure to review activities and outcomes related to our update of recommendations…. The final recommendations should provide an evidence-based tool for states and other end-users.
  • But existing guidelines for sealant use in school-based programs were last revised over 10 years ago. Since then, new information has become available:
  • Members of the expert panel are listed here and represent recognized experts in science and research, practice, and policy relevant to school sealant programs and representatives from interested organizations. In addition to ASTDD and AAPHD there are representatives other interested organizations, for example, the American Academy of Pediatric Dentistry the American Dental Association the American Association of Community Dental Programs and the National Association of School Nurses It’s also important to note that dentists, hygienists, nurses and physicians were represented, and that dentists from both the private sector and the public health sector were included. And prominent scientists with expertise in cariology, sealant materials, and public health policy and practice.
  • And, we noted that non-cavitated lesions can become cavitated simply through pressure from the explorer during the typical examination.
  • These fill the gap between the recommendations of the Task Force on Community Preventive Services, which focused only the effectiveness of sealants in school programs to reduce the incidence of caries on permanent molars by 60% after up to 5 years, and the practical guidance of the Seal America manual. Comprehensive plan And while they provide a level of evidence that should increase our confidence in promoting them to various stakeholders, effective dissemination will require our best efforts.
  • Thank you
  • Presentation

    1. 1. Evidence-based Recommendations for School-based Sealant Programs CAPT William Bailey Division of Oral Health [email_address]
    2. 2. This presentation has not been cleared for dissemination and does not represent the opinion of the Centers for Disease Control and Prevention or the Department of Health and Human Services.
    3. 3. Reasons for Updating Recommendations <ul><li>Existing guidelines last revised in 1994 </li></ul><ul><li>New information available </li></ul><ul><li>To address some dentists’ </li></ul><ul><li> concerns about school </li></ul><ul><li>programs, such as </li></ul><ul><ul><ul><li>Sealing “incipient” </li></ul></ul></ul><ul><ul><ul><li> tooth decay </li></ul></ul></ul><ul><ul><ul><li>Methods used for assessment, </li></ul></ul></ul><ul><ul><ul><li>tooth preparation, and placement </li></ul></ul></ul><ul><ul><ul><li>in school sealant programs </li></ul></ul></ul><ul><ul><li>To assure that current guidelines </li></ul></ul><ul><ul><li>reflect the state of the science </li></ul></ul>
    4. 4. Panel Members <ul><li>Chair – </li></ul><ul><li>Gary Rozier, DDS, MPH </li></ul><ul><li>University of North Carolina at Chapel Hill </li></ul><ul><li>Panelists – </li></ul><ul><li>Diane Brunson, RDH, MPH </li></ul><ul><li>Colorado Dept. of Public Health/Environ </li></ul><ul><li>David K. Curtis, DMD </li></ul><ul><li>American Academy of Pediatric Dentistry </li></ul><ul><li>Margherita Fontana, DDS, PhD </li></ul><ul><li>Indiana University School of Dentistry </li></ul><ul><li>Harold Haering, DMD </li></ul><ul><li>American Dental Association </li></ul><ul><li>Larry Hill, DDS, MPH </li></ul><ul><li>Cincinnati Health Department </li></ul><ul><li>Jayanth Kumar, DDS, MPH </li></ul><ul><li>New York State Department of Health </li></ul><ul><li>Mark Mallatt, DDS, MSD </li></ul><ul><li>Indiana State Department of Health </li></ul><ul><li>Daniel M. Meyer, DDS </li></ul><ul><li>American Dental Association </li></ul><ul><li>Wanda R. Miller, RN, MA, NCSN, FNASN </li></ul><ul><li>National Association of School Nurses </li></ul><ul><li>Susan M. Sanzi-Schaedel, RDH, MPH </li></ul><ul><li>Multnomah County Health Department </li></ul><ul><li>Mark Siegal, DDS, MPH </li></ul><ul><li>Ohio Department. of Health </li></ul><ul><li>Richard Simonsen, DDS, MS </li></ul><ul><li>Arizona College of Dentistry and Oral Health </li></ul><ul><li>Benedict I. Truman, MD, MPH </li></ul><ul><li>Centers for Disease Control and Prevention </li></ul><ul><li>Domenick T. Zero, DDS, MS </li></ul><ul><li>Indiana University School of Dentistry </li></ul>
    5. 5. Reducing Decay on Sound Teeth <ul><li>1. What is the effectiveness of sealants in preventing caries initiation on sound pit-and-fissure surfaces? </li></ul><ul><li>78% at one year; 59% at four or more years (10 studies – Llodra 1993) </li></ul><ul><li>87% at one year; 60% at 48-54 months (5 studies - Ahovuo-Saloranta 2008) </li></ul><ul><li>33% at 2-5 years (13 studies – Mejare 2003)** </li></ul><ul><li>**Included first generation sealant materials no longer marketed in the United States </li></ul>
    6. 6. <ul><li>2. What is the effectiveness of sealants in preventing progression of non-cavitated** or incipient carious lesions to cavitation? </li></ul><ul><li>Sealants reduced the percentage of lesions that progressed by 71% for up to 5 years (Griffin 2008) </li></ul><ul><li>**Non-cavitated lesions defined as having no discontinuity or break in the enamel surface </li></ul>Preventing progress of decay in Carious Teeth
    7. 7. J Dent Res 2008; 87(2): 169-174 Sealants reduced the percentage of non-cavitated caries lesions that progressed by 71%.
    8. 8. <ul><li>3. What is the effectiveness of sealants in reducing bacteria levels in cavitated carious lesions? </li></ul><ul><li>Review of evidence found no significant increases of bacteria under sealants (Oong 2008) </li></ul><ul><li>Lowered the number of viable bacteria, including S. mutans and lactobacilli, by at least 100-fold </li></ul><ul><li>Reduced the number of lesions with any viable bacteria by about 50% </li></ul>Reducing bacteria in cavitated lesions
    9. 9. JADA 2008; 139(3): 271-278 Sealants lowered bacteria levels by at least 100-fold.
    10. 10. Methods to Detect Caries <ul><li>4. Which caries assessment methods should be used in school sealant programs to differentiate sound or non-cavitated surfaces from those that are cavitated or have signs of dentinal caries? </li></ul><ul><li>Visual or visual/tactile assessment to detect frank cavitation is adequate </li></ul><ul><li>Explorer should be used only with gentle pressure to detect break in surface continuity </li></ul>
    11. 11. <ul><li>4. Which caries assessment methods should be used in school sealant programs to differentiate sound or non-cavitated surfaces from those that are cavitated or have signs of dentinal caries? </li></ul><ul><li>Radiographs are not needed for assessment </li></ul><ul><li>Magnification not necessary </li></ul><ul><li>Other diagnostic aids not needed </li></ul>Methods to Detect Caries (cont.)
    12. 12. Probing with Sharp Explorer… Ekstrand K, Caries Res 1987 Non-cavitated lesions can become cavitated simply through pressure from the explorer during the typical examination. Based on slide of M Fontana, DDS, PhD
    13. 13. Methods to Clean Teeth Prior to Sealant Placement <ul><li>5. What surface cleaning methods or techniques are recommended by manufacturers for unfilled resin sealants commonly used in school programs? </li></ul><ul><li>Too few studies to determine effect, but available studies suggest no difference in sealant retention. </li></ul><ul><li>Toothbrush prophylaxis is adequate </li></ul><ul><li>Gillcrist JA, JPHD (1998); Griffin SO, JADA (2008);Muller-Bolla M, CDOE (2006) </li></ul>
    14. 14. JADA 2009; 2009;140;38-46 Sealant retention after surface cleaning with toothbrush prophylaxis were at least as high as those associated with handpiece prophylaxis.
    15. 15. Other surface preparation <ul><li>6. What is the effect of clinical procedures – specifically surface cleaning or mechanical preparation methods with a bur before acid etch – on sealant retention? </li></ul><ul><li>Limited and inconsistent findings; no compelling evidence that cleaning surface with air abrasion or widening fissures with bur (enameloplasty) increase retention </li></ul>
    16. 16. Four-handed vs. Two-handed Technique <ul><li>7. Does use of four-handed technique in comparison to two-handed technique improve sealant retention? </li></ul><ul><li>No comparative clinical studies to determine effect </li></ul><ul><li>Recent descriptive study suggests that four-handed technique may increase retention (Multivariate descriptive analysis) (Griffin 2008) </li></ul>
    17. 17. JADA 2008; 139(3): 281-289 Four-handed delivery is associated with slightly higher sealant retention.
    18. 18. Risk of Teeth that Loose Sealants <ul><li>8. Are teeth that lose sealants at higher risk of caries than teeth that were never sealed? </li></ul><ul><li>Meta-analysis found that teeth with fully or partially lost sealants were not at higher risk for caries than teeth that were never sealed (Griffin 2009) </li></ul>
    19. 19. JADA 2009;140;415-423 Formerly sealed teeth at no greater risk for dental caries than teeth that were never sealed.
    20. 20. Recommendations School-Based Sealant Programs <ul><li>Differentiate cavitated and non-cavitated lesions </li></ul><ul><ul><li>Unaided visual assessment is appropriate and adequate </li></ul></ul><ul><ul><li>Dry teeth prior to assessment with cotton rolls, guaze, or compressed air </li></ul></ul><ul><ul><li>An explorer may be used “gently” </li></ul></ul><ul><ul><li>Radiographs are unneccessary </li></ul></ul><ul><ul><li>Other diagnostic techniques are not required </li></ul></ul>
    21. 21. Recommendations School-Based Sealant Programs <ul><li>Seal sound and non-cavitated surfaces of posterior teeth prioritizing first and second molars </li></ul><ul><li>Clean the tooth surface </li></ul><ul><ul><li>Toothbrush prophylaxis can be used </li></ul></ul><ul><ul><li>Additional surface preparation methods, such as air abrasion or enameloplasty, are not recommended </li></ul></ul>
    22. 22. Recommendations School-Based Sealant Programs <ul><li>Use four-handed technique, when resources allow </li></ul><ul><li>Seal teeth of children even if follow-up cannot be assured </li></ul><ul><li>Evaluate sealant retention within one year </li></ul>
    23. 23. Next Steps <ul><li>Publish CDC recommendations for school-based sealant programs </li></ul><ul><li>Disseminate to stakeholders (e.g., public health professionals, clinical dentistry, school nurses and administration) </li></ul><ul><li>Identify and address remaining gaps in knowledge and barriers to implementation </li></ul>
    24. 24.