States are halting dental sealant programs

Dental care remains the largest unmet health need among US children.¹ Left untreated, dental disease can lead to emergency room (ER) visits, hospitalization, and even death.² In 2008, children went to the ER more than 215,000 times for preventable dental problems at a cost of more than $104 million.³ Children with untreated tooth decay not only suffer from pain and infection, but have problems with eating, speaking, socializing, sleeping and learning, which can impair school performance.⁴

Low-income children are particularly vulnerable. Their caries rates are higher and they are less likely to receive dental care than their better off peers.⁵ In 2012, more than 4 million children did not receive needed dental care because their families could not afford it.⁶ The following year, more than 16 million children enrolled in Medicaid—nearly 50 percent—did not receive dental care.⁷

Dental sealants are a critical preventive service

Tooth decay, one of the most common ailments in children, is largely preventable. According to the Centers for Disease Control and Prevention, dental sealants—plastic coatings placed on the chewing surfaces of teeth—can reduce tooth decay by 80% in the two years after placement and continue to be effective for nearly five years.⁸ Research finds that sealants are safe⁹ and they help shield the grooved areas of the tooth where fluoride toothpaste is not as protective.¹⁰ Because sealants are such an effective means of preventing tooth decay, they are approved by the American Dental Association.¹¹

Dental sealants are one-third the cost of a filling, so their use can save patients, families and states money.¹² School-based sealant programs are the optimal way to reach children—especially low-income children who have trouble accessing dental care. However, despite the compelling evidence, a survey conducted between 2011 and 2012 found that only four in ten young people aged 6 to 19 had even one sealant.¹³

Rating of states

In 2013, the Pew Children’s Dental Campaign released a report that rated all 50 states and the District of Columbia on their performance in filling the teeth of low-income children. This tracking report describes how states have progressed toward this goal over the past two years,* with analysis based on surveys of dental directors and state dental boards.

Pew rated states and the District of Columbia on four benchmarks that reflect the reach, effectiveness and efficiency of sealing programs:

1. The extent to which sealant programs serve high-need schools, which most states define as schools where at least half the students participate in the National School Meal Program.**
2. If hygienists are allowed to place sealants in school programs without prior examination by the dentist.†
3. If states collect data and participate in a national database.
4. Percentage of students receiving sealants statewide (marks progress toward the 2010 Healthy People goals—a federal initiative to provide science-based 10-year national goals to improve the health of all Americans).‡

Mention newsletters

* Pew’s rating reflects state policies as of July 31, 2014.

** Benedict I. Truman et al., “Reviews of Evidence on Interventions to Prevent Dental Caries, Oral and Pharyngeal Cancers, and Sports-related Craniofacial Injuries”, American Journal of Preventive Medicine, 23 (2002): 21-54,

† In this report, we refer to the laws and regulations that define the scope of practice for hygienists as the state’s “practice act.”

‡ The federal Healthy People initiative was launched to provide science-based, 10-year national goals to improve the health of all Americans. In dental health, its goal is to have 50 percent of the nation’s children receive sealants by 2010. Note that Pew based its benchmarks for the 2012 and 2014 reports on the Healthy People 2010 sealant goals; not in those of Healthy People 2020.

IMPORTANT FINDINGS

Based on Pew’s analysis of surveys, most states are failing to enact policies that provide sealants to low-income and at-risk children. While several states have made improvements in providing dental sealants to low-income children over the past two years, the study found that most states fall short of national goals. Seventy-two percent of states and the District of Columbia received a grade of C or worse. (See the Findings section for status data.)

ESPECIALLY:

• Only five states earned an A or A-minus for their sealant performance, of which only three—Maine, New Hampshire and Oregon—received the maximum possible marks.
• Nine states earned a B or B minus. Of those, five still reach fewer than half of high-needs schools with their sealant programs, and four fell short of Healthy People’s goal of providing sealants to at least half of their 8-year-olds.
• Nineteen states received a C or C-minus.
• Fourteen states were given a D or D minus.
• Three states—Hawaii, New Jersey and Wyoming—and the District of Columbia received an F, the same grade they received in the 2013 report.

Overall, 12 states improved their scores from the 2013 report, 32 states remained unchanged and seven states lost ground. Our analysis also shows that:

• Two states — Missouri and Wyoming — do not have high-need school sealing programs.
• Thirty-nine states and the District of Columbia do not have sealing programs in most high-needs schools.
• Thirteen states and the District of Columbia require a dentist to examine a child before a dental hygienist in a school program can place a filling. Known as the pre-exam requirement, this rule runs counter to growing evidence that a dental exam is unnecessary before a filling is placed. Six states have abolished the prior exam rule since 2012.
• Twelve states and the District have failed to collect and submit sealant data for school-aged children for the past five years to the National Oral Health Surveillance System (NOHSS), a database that informs policymakers of trends and progress. Four of those 12, and the District, have never submitted evidence.
• Only 13 states have met the Healthy People 2010 goal of sealing the permanent molars of at least half of their 8-year-olds.

This report focuses exclusively on the performance of sealant programs and the extent to which states can improve access to this treatment for at-risk children. However, many other factors affect a state’s overall performance in oral health, such as the extent to which its population has dental insurance, the availability of Medicaid providers, and access to fluoridated water. Therefore, even states that scored high on sealants may have room for improvement in other areas.

END NOTES

1. Paul W. Newacheck et al., “The Unmet Health Needs of America’s Children,” Pediatrics 105, no. 4 Pt. 2 (2000): 989–97, and Barbara Bloom, Lindsey I. Jones, and Gulnur Freeman, “Summary of Health Statistics for US Children: National Health Interview Survey, 2012,” National Center for Health Statistics, Vital and Health Statistics 10 , no. 258 (2013): 5–6 and Tables 13 and 16;
2. Veerasathpurush Allareddy et al., “Hospital-Based Emergency Department Visits Involving Dental Conditions: Profiles and Predictors of Adverse Outcomes and Resource Utilization,” Journal of the American Dental Association 145, no. 4 (2014): 331–7.
3. Veerasathpurush Allareddy et al., “Hospital-Based Emergency Department Visits with Dental Conditions Among Children in the United States: Nationwide Epidemiologic Data,” Pediatric Dentistry 36, no. 5 (2014): 393–9,
4. Katrina Holt and Ruth Barzel, “Oral Health and Learning: When Children’s Health Suffers, So Does their Ability to Learn” (3rd ed.), National Maternal and Child Oral Health Resource Center (2013) and US General Accounting Office, Oral Health: Dental disease is a chronic problem among low-income and vulnerable populations (2000);
5. Bruce A. Dye et al., Trends in Oral Health Status: United States, 1988–1994 and 1999–2004, National Center for Health Statistics, Vital and Health Statistics 11, no. 248 (2007): 23, Table 10,
6. Bloom et al., “Summary of health statistics for US children,” National Health Interview Survey, 2012, Vital Health Stat 10(258) 2013.
7. This figure counts children up to the age of 18 who are eligible for the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) benefit. US Department of Health and Human Services and Centers for Medicare & Medicaid Services (2014). EPSDT Annual Participation Report, Form CMS-416 (National) Fiscal Year 2013,
8. Susan O. Griffin et al., “Use of dental care and effective preventive services in caries prevention among US children and adolescents—Medical Expenditure Panel Survey, United States, 2003–2009 and National Health and Nutrition Examination Survey, United States, 2005 –2010, “Norbidity and Mortality Weekly Report (September 12, 2014) and Anneli Ahovuo-Saloranta et al., “Sealants for Preventing Dental Decay in the Permanent Teeth”, Cochrane Database of Systematic Reviews, art. no. CD001830, doi: 10.1002 /14651858.CD001830.pub4.
9. Anneli Ahovuo-Saloranta et al., “Sealants for Preventing Dental Decay in the Permanent Teeth”, Cochrane Database of Systematic Reviews, 3, art. no. CD001830, doi: 10.1002/14651858.CD001830.pub4.; AF Fleisch et al., “Bisphenol A and Related Compounds in Dental Materials,” Pediatrics 126, no. 4 (2010): 760–768,
10. National Institutes of Health, “Dental Sealants in the Prevention of Tooth Decay”, Consensus Development Conference Statement 4, no. 11 (5–7 December 1983),
11. Jean Beauchamp et al., “Evidence-based Clinical Recommendations for the Use of Pit-and-Fissure Sealants: A Report of the American Dental Association on Scientific Affairs”, Journal of the American Dental Association 139, no. 3 (March 2008): 257–68,
12. American Dental Association, Health Policy Institute, “2013 Survey of Dental Fees” (2014). The national median charge (50th percentile) among general practice dentists for a sealant (procedure code D1351) is $48, and the national median charge (50th percentile) for a composite posterior filling (procedure code D2391) is $160.
13. Bruce A. Dye et al., “Dental Caries and Sealant Prevalence in Children and Adolescents in the United States, 2011-2012”, National Center for Health Statistics, data brief no. 191, National Center for Health Statistics (2015), databriefs/db191.pdf.