States Stalled on Dental Sealant Programs

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

Low-income children are particularly vulnerable. Their rates of tooth decay are higher, and they are less likely to receive dental care than are 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 next year, over 16 million children who were enrolled in Medicaid—almost 50 percent—received no dental care.⁷

Dental sealants are a critical preventive service

Tooth decay, one of the most common conditions among 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 decay by 80 percent in the two years after placement, and continue to be effective for nearly five years.⁸ Research finds that sealants are safe⁹ and help to shield 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 have been endorsed 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 Sealant programs based in schools are an optimal way to reach children—especially low-income children who have trouble accessing dental care. Yet despite compelling evidence, a survey conducted between 2011 and 2012 found that only four out of ten 6- to 19- year-olds had even one sealant.¹³

Grading the states

In 2013, the Pew children’s dental campaign released a report evaluating all 50 states and the District of Columbia on their performance in sealing the teeth of low-income children. This follow-up report describes whether states have progressed on this goal over the last two years,* with analysis based on surveys of dental directors and state dental boards.

Pew graded the states and the District of Columbia on four benchmarks that reflect the reach, efficiency, and effectiveness of their sealant programs:

1. The extent to which sealant programs are serving high-need schools, which most states define as schools where at least half of the students participate in the National School Lunch Program.**
2. Whether hygienists are allowed to place sealants in school programs without a dentist’s prior exam.†
3. Whether states collect data and participate in a national database.
4. The proportion of students receiving sealants across the state (marking progress toward reaching the 2010 objectives of Healthy People—a federal initiative to provide science-based, 10-year national goals for improving the health of all Americans).‡

State fact sheets

* Pew’s assessment 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, http://www.thecommunityguide.org/oral/oralajpm-ev-rev.pdf.

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

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

KEY FINDINGS

Based on Pew’s analysis of the 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 delivering dental sealants to low-income children over the past two years, the study found that most states are not meeting national goals. Seventy-two percent of states and the District of Columbia received a grade of C or worse. (See the Findings section for state data.)

Specifically:

• Only five states earned an A or A minus for their sealant performance, of which just three—Maine, New Hampshire, and Oregon—received the maximum possible points.
• Nine states earned a B or B minus. Of these, five continue to reach fewer than half of high-need schools with their sealant programs, and four did not meet the Healthy People goal of providing at least half of their 8-year-olds with sealants.
• 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 F’s, the same grade they were given in the 2013 report.

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

• Two states—Missouri and Wyoming—have no sealant programs in high-need schools.
• Thirty-nine states and the District of Columbia lack sealant programs in most of their high-need schools.
• Thirteen states and the District of Columbia require a dentist to examine a child before a dental hygienist in a school-based program can place a sealant. Known as a prior exam requirement, this rule runs counter to growing evidence that a dentist’s exam is not necessary before a sealant is put in place. Six states have abolished the prior exam rule since 2012.
• Twelve states and the District have failed to collect and submit sealant data on school-age children within the past five years to the National Oral Health Surveillance System (NOHSS), a database that informs policymakers on trends and progress. Four of these 12, and the District, have never submitted data.
• 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 solely on the performance of sealant programs and the degree to which states can improve access to this treatment for at-risk children. However, many other factors affect a state’s overall performance on 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 received high grades 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, http://pediatrics.aappublications.org/content/105/Supplement_3/989.full.pdf+html; and Barbara Bloom, Lindsey I. Jones, and Gulnur Freeman, “Summary Health Statistics for U.S. 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, http://www.cdc.gov/nchs/data/series/sr_10/sr10_258.pdf.
2. Veerasathpurush Allareddy et al., “Hospital-Based Emergency Department Visits Involving Dental Conditions: Profile and Predictors of Poor 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 Epidemiological Data,” Pediatric Dentistry 36, no. 5 (2014): 393–9, http://www.ncbi.nlm.nih.gov/pubmed/25303506.
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), http://www.mchoralhealth.org/PDFs/learningfactsheet.pdf; and U.S. General Accounting Office, Oral Health: Dental Disease Is a Chronic Problem Among Low Income and Vulnerable Populations (2000), http://www.gao.gov/new.items/he00072.pdf.
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, http://www.cdc.gov/nchs/data/series/sr_11/sr11_248.pdf.
6. Bloom et al., “Summary Health Statistics for U.S. Children,” National Health Interview Survey, 2012, Vital Health Stat 10(258) 2013.
7. This figure counts children through age 18 eligible for the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit. U.S. Department of Health and Human Services and Centers for Medicare & Medicaid Services (2014). Annual EPSDT participation report, Form CMS-416 (national) fiscal year 2013, http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Earlyand-Periodic-Screening-Diagnostic-and-Treatment.html.
8. Susan O. Griffin et al., “Use of Dental Care and Effective Preventive Services in Preventing Tooth Decay Among U.S. Children and Adolescents—Medical Expenditure Panel Survey, United States, 2003–2009, and National Health and Nutrition Examination Survey, United States, 2005–2010,” Morbidity and Mortality Weekly Report (Sept. 12, 2014), http://www.cdc.gov/mmwr/preview/mmwrhtml/su6302a9.htm?s_cid=su6302a9_w; and 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.
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.; A.F. Fleisch et al., “Bisphenol A and Related Compounds in Dental Materials,” Pediatrics 126, no. 4 (2010): 760–768, http://pediatrics.aappublications.org/content/early/2010/09/06/peds.2009-2693.abstract.
10. National Institutes of Health, “Dental Sealants in the Prevention of Tooth Decay,” Consensus Development Conference Statement 4, no. 11 (Dec. 5–7, 1983), http://consensus.nih.gov/1983/1983DentalSealants040html.htm.
11. Jean Beauchamp et al., “Evidence-Based Clinical Recommendations for the Use of Pit-and-Fissure Sealants: A Report of the American Dental Association Council on Scientific Affairs,” Journal of the American Dental Association 139, no. 3 (March 2008): 257–68, http://www.dental.theclinics.com/article/S0011-8532(08)00080-3/pdf.
12. American Dental Association, Health Policy Institute, “2013 Survey of Dental Fees” (2014). The national median (50th percentile) charge among general practice dentists for a sealant (procedure code D1351) is $48, and the national median (50th percentile) charge for a one surface posterior composite 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), http://www.cdc.gov/nchs/data/ databriefs/db191.pdf.