Evidence-based Evidence-based Recommendations for Recommendations for School-based Sealant School-based Sealant ProgramsPrograms

CAPT William BaileyDivision of Oral Healthwbailey@cdc.gov

This presentation has not This presentation has not been cleared for been cleared for dissemination and does not dissemination and does not represent the opinion of the represent the opinion of the Centers for Disease Control Centers for Disease Control and Prevention or the and Prevention or the Department of Health and Department of Health and Human Services.Human Services.

Reasons for Updating Recommendations Existing guidelines last revised in 1994 New information available To address some dentists’To address some dentists’

concerns about school concerns about school

programs, such as programs, such as Sealing “incipient”Sealing “incipient”

tooth decaytooth decay Methods used for assessment,Methods used for assessment,

tooth preparation, and placementtooth preparation, and placement

in school sealant programsin school sealant programs

– To assure that current guidelines To assure that current guidelines

reflect the state of the sciencereflect the state of the science

Panel MembersPanel Members

Chair –

Gary Rozier, DDS, MPHUniversity of North Carolina at Chapel Hill

Panelists –

Diane Brunson, RDH, MPH Colorado Dept. of Public Health/Environ

David K. Curtis, DMDAmerican Academy of Pediatric Dentistry

Margherita Fontana, DDS, PhDIndiana University School of Dentistry

Harold Haering, DMDAmerican Dental Association

Larry Hill, DDS, MPHCincinnati Health Department

Jayanth Kumar, DDS, MPHNew York State Department of Health

Mark Mallatt, DDS, MSDIndiana State Department of Health

Daniel M. Meyer, DDSAmerican Dental Association

Wanda R. Miller, RN, MA, NCSN, FNASNNational Association of School Nurses

Susan M. Sanzi-Schaedel, RDH, MPHMultnomah County Health Department

Mark Siegal, DDS, MPHOhio Department. of Health

Richard Simonsen, DDS, MSArizona College of Dentistry and Oral Health

Benedict I. Truman, MD, MPHCenters for Disease Control and Prevention

Domenick T. Zero, DDS, MSIndiana University School of Dentistry

Reducing Decay on Sound Teeth

1. What is the effectiveness of sealants in preventing caries initiation on sound pit-and-fissure surfaces? 78% at one year; 59% at four or more years (10 78% at one year; 59% at four or more years (10 studies – Llodra 1993)studies – Llodra 1993) 87% at one year; 60% at 48-54 months (5 87% at one year; 60% at 48-54 months (5 studies - Ahovuo-Saloranta 2008)studies - Ahovuo-Saloranta 2008) 33% at 2-5 years (13 studies – Mejare 2003)**33% at 2-5 years (13 studies – Mejare 2003)**

**Included first generation sealant materials no longer marketed in the United States**Included first generation sealant materials no longer marketed in the United States

2. What is the effectiveness of sealants in preventing progression of non-cavitated** or incipient carious lesions to cavitation?

Sealants reduced the percentage of lesions that progressed by 71% for up to 5 years (Griffin 2008)

**Non-cavitated lesions defined as having no discontinuity or break in the enamel surface

Preventing progress of decayin Carious Teeth

J Dent Res 2008; 87(2): 169-174J Dent Res 2008; 87(2): 169-174

Sealants reduced the percentage of non-Sealants reduced the percentage of non-cavitated caries lesions that progressed by cavitated caries lesions that progressed by 71%.71%.

3. What is the effectiveness of sealants in reducing bacteria levels in cavitated carious lesions?

Review of evidence found no significant Review of evidence found no significant increases of bacteria under sealants (Oong increases of bacteria under sealants (Oong 2008)2008)

Lowered the number of viable bacteria, Lowered the number of viable bacteria, including including S. mutansS. mutans and lactobacilli, by at least and lactobacilli, by at least 100-fold100-fold

Reduced the number of lesions with any viable Reduced the number of lesions with any viable bacteria by about 50%bacteria by about 50%

Reducing bacteria in cavitated lesions

JADA 2008; 139(3): 271-278 JADA 2008; 139(3): 271-278

Sealants lowered bacteria levels by at least Sealants lowered bacteria levels by at least 100-fold.100-fold.

Methods to Detect Caries

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? Visual or visual/tactile assessment to detect Visual or visual/tactile assessment to detect frank cavitation is adequatefrank cavitation is adequate Explorer should be used only with gentle Explorer should be used only with gentle pressure to detect break in surface continuitypressure to detect break in surface continuity

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? Radiographs are not needed for Radiographs are not needed for assessmentassessment Magnification not necessaryMagnification not necessary

Other diagnostic aids not neededOther diagnostic aids not needed

Methods to Detect Caries (cont.)

Probing with Sharp Probing with Sharp Explorer…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

Methods to Clean Teeth Prior to Sealant Placement

5. What surface cleaning methods or techniques are recommended by manufacturers for unfilled resin sealants commonly used in school programs? Too few studies to determine effect, but available studies suggest no difference in sealant retention. Toothbrush prophylaxis is adequate

Gillcrist JA, JPHD (1998); Griffin SO, JADA (2008);Muller-Bolla M, CDOE (2006)

JADA 2009; 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.

Other surface preparation

6. What is the effect of clinical procedures – specifically surface cleaning or mechanical preparation methods with a bur before acid etch – on sealant retention?

Limited and inconsistent findings; no Limited and inconsistent findings; no compelling evidence that cleaning surface compelling evidence that cleaning surface with air abrasion or widening fissures with with air abrasion or widening fissures with bur (enameloplasty) increase retentionbur (enameloplasty) increase retention

Four-handed vs. Two-handedTechnique7. Does use of four-handed technique in comparison to two-handed technique improve sealant retention?

No comparative clinical studies to determine effect

Recent descriptive study suggests that four-handed technique may increase retention (Multivariate descriptive analysis) (Griffin 2008)

JADA 2008; 139(3): 281-289JADA 2008; 139(3): 281-289

Four-handed delivery is associated with Four-handed delivery is associated with slightly higher sealant retention.slightly higher sealant retention.

Risk of Teeth that Loose Sealants

8. Are teeth that lose sealants at higher risk of caries than teeth that were never sealed?

Meta-analysis found that teeth with fully Meta-analysis found that teeth with fully or partially lost sealants were not at or partially lost sealants were not at higher risk for caries than teeth that were higher risk for caries than teeth that were never sealed (Griffin 2009)never sealed (Griffin 2009)

JADA JADA 2009;140;415-423

Formerly sealed teeth at no greater risk for dental caries than teeth that were never sealed.

Recommendations School-Based Sealant Programs Differentiate cavitated and non-Differentiate cavitated and non-

cavitated lesionscavitated lesions– Unaided visual assessment is appropriate Unaided visual assessment is appropriate

and adequateand adequate– Dry teeth prior to assessment with cotton Dry teeth prior to assessment with cotton

rolls, guaze, or compressed airrolls, guaze, or compressed air– An explorer may be used “gently” An explorer may be used “gently” – Radiographs are unneccessaryRadiographs are unneccessary– Other diagnostic techniques are not Other diagnostic techniques are not

requiredrequired

Recommendations School-Based Sealant Programs Seal sound and non-cavitated

surfaces of posterior teeth prioritizing first and second molars

Clean the tooth surface– Toothbrush prophylaxis can be used– Additional surface preparation methods,

such as air abrasion or enameloplasty, are not recommended

Recommendations School-Based Sealant Programs Use four-handed technique, when Use four-handed technique, when

resources allowresources allow Seal teeth of children even if Seal teeth of children even if

follow-up cannot be assuredfollow-up cannot be assured Evaluate sealant retention within Evaluate sealant retention within

one yearone year

Next StepsNext Steps

Publish CDC recommendations for school-based sealant programs

Disseminate to stakeholders (e.g., public health professionals, clinical dentistry, school nurses and administration)

Identify and address remaining gaps in knowledge and barriers to implementation

www.cdc.gov/oralhealthwww.cdc.gov/oralhealth