"Although dental problems don't command the instant fears associated with low birth weight, fetal death or cholera, they do have the consequence of wearing down the stamina of children and defeating their ambitions. Bleeding gums, impacted teeth and rotting teeth are routine matters...Children get used to feeling constant pain. They go to sleep with it. They go to school with it...Children live for months whith pain that grown-ups would find unendurable. The gradual attrition of accepted pain erodes their energy and aspirations...to me, most shocking is to see a child with an abscess that has been inflamed for weeks and that he has simply lived with and accepts as part of the routine of life. Many teachers in urban schools have seen this. It is almost commonplace."
Jonathon Kozol, Savage Inequalities: Children in America's Schools
INTRODUCTION
Dental caries (tooth decay) remain the single most common disease of childhood, occuring five to eight times more commonly than asthma, which is the second most common disease of childhood (Edelstein & Douglas, 1995). Although tooth decay has declined significantly among U.S. children in the past 20 years, it is disproportionately prevalent in poor children. Preventive measures like fluoridated water and toothpaste have played a large role in decreasing the amount of smooth surface decay, but fluoride has its least preventive effect on pit-and-fissure caries (ADA, 1997). Dental sealants are the most preventive measure against pit-and-fissure caries, and have proved to be effective at not only preventing tooth decay before it starts, but also halting the progress of tooth decay in its earliest stages. Therefore, besides fluoride, dental sealants are also crucial to preventive dental care.
PREVALENCE
One of the Healthy People 2010 Objectives for Oral Health aims to increase to at least 70% the proportion of children aged 8 and 14 who have received protective sealants in permanent molar teeth. However, the baseline, from 1988 to 1994, is 23% of 8-year-old and 24% of 14-year-old children who have received sealants in permanent molar teeth.
BACKGROUND ON DENTAL SEALANTS
Dental sealants were developed in the 1970s and have been found highly effective in the prevention of tooth decay on the chewing surfaces of teeth. Sealants are thin plastic coatings which are applied to the chewing surfaces of the molars where most tooth decay in children and teens occurs. This plastic resin bonds into the depressions and grooves (pits and fissures) of the chewing surfaces of back teeth. The sealant acts as a barrier, protecting enamel from plaque and acids. When combine with fluorides, which protect enamel surfaces between teeth, a major caries reduction can be anticipated.
When applying dental sealants, dental professionals must ensure that the sealant is properly placed, remains intact and is periodically replenished and maintained. With complete retention, sealed surfaces are virtually impervious to decay. After one year, studies report 92% to 96% retention; after five years, 67% to 82% retention. One study of long-term retention of chemically activated sealants showed 41% to 57% of sealants were completely covered after ten years. One 15-year study showed complete sealant retention of 27.6% and partial retention of 35.4% (American Dental Association, 1997). Other studies showed that sealants halt the progression of pit-and-fissure carious lesions intentionally sealed.
WHO SHOULD GET DENTAL SEALANTS?
Dental sealants are strongly recommended on the first permanent molars of children. First molars usually come into the mouth when a child is about six years of age. These teeth are more difficult for a young child to brush because the grooves tend to be deeper, and sealants protect these permanent teeth from extensive destruction by protecting the tooth enamel from plaque and acids (Berman, 1993). Second molars appear at about age twelve. It is best if the sealant is applied soon after the molars have erupted, before the teeth have a chance to decay. For that reason, children between the ages of five and fifteen benefit the most from sealants (Center for Disease Control).
Minority and non-minority children continue to need dental services. The latter group has more of their services needs met than their minority counterparts. In fact, a large percentage of minority children are not receiving needed clinical preventive dental services since they are much less likely to have dental insurance or a regular source of dental care (Waldman, 1990). This segment of the pediatric population is growing rapidly and disproportionately. This leads to increased disparities in oral health, with tooth decay disproportionately distributed and the overall population caries rates in primary teeth on the rise.
Socioeconomic status (SES) is another indicator of children's dental health. Several published studies show children from lower SES families to have a trend toward higher caries prevalence rates than children from higher SES families. Among low-income children, almost 50% of tooth decay remains untreated, resulting in pain, dysfunction, underweight, and poor appearance (Center for Disease Control). Dental sealant use has been shown to increase with higher SES, which reflects the trend that higher SES levels translate to higher rates of dental insurance coverage.
BARRIERS TO RECEIVING DENTAL SEALANTS
Despite the wide acceptance of sealants as a safe, cost-effective preventive dental treatment found to be effective in preventing caries and in arresting the progression of caries, they have not been widely used in general dental practice. Those more likely to place sealants on patients include recent dental graduates, female dentists, and practices with more children (i.e. pediatric dentists). There are several factors contributing to the low use rate of dental sealants:
Patient/parent opinion/knowledge: often times, parents are unaware of the benefits of sealants and do not request them for their children
Insufficient emphasis on preventive services that are recommended
Dental sealants are low-technology products that lack the appeal and remuneration of high-end products
Inadequate reimbursement for prevention services
Reimbursement knowledge of the dentist/third party reimbursement
Dental school experience
The dentist's fear of placing sealants over a potentially carious pit or fissure and poor retention of sealant material
The high caries rates mean that there are fewer decay-free teeth that are available to be sealed
Infrequent dental visits delay sealant application so long that teeth have a chance to decay
CONCLUSION
Low and modest income children have the greatest dental needs and the least dental care. The key issues in dental sealant utilization are acceptability, availability, accessibility, affordability, and accountability. Individual provider and community efforts to achieve the national objective of increasing sealant utilization in children should include strategies to:
Increase access to dental care, particularly for uninsured, poor, and minority populations
Encourage greater promotion of dental sealants by oral health practitioners, particularly in vulnerable populations of children who are at moderate or high risk for tooth decay
Improve public knowledge regarding the value of sealants
Promote increased coverage for the procedure under third-party payment systems
Establish dental utilization incentives or performance targets in contracts with health plans
Fund school-based dental sealant programs for low-income children not covered by private insurance or publicly-funded programs such as Denti-Cal and Healthy Families
Greater use of sealants by dental practitioners should result in further reductions in pit-and-fissure caries. Therefore, sealants should be used as part of a child's total preventive dental care. A complete preventive dental program includes use of sealants, fluoride, plaque removal, careful food choices, and regular dental care. Appropriate use of sealants can save time, money, and the discomfort associated with dental treatment procedures. Dental health professionals, child health advocates, and state agencies must take action to ensure that sealants are made available to the children who rarely receives them.
| Romila Tandingan |
| Epi 414 Project |
| rgtan@aol.com |