By Camille V. Gannam, D.M.D., M.S. and Roopa P. Gandhi, B.D.S., M.S.D.
From the Winter 2017 Journal of the Colorado Dental Association
Introduction
Disparities among children can be found in nearly every marker of health, however, oral health disparities are particularly disturbing given that dental caries, for the most part, are completely preventable. Despite a significant reduction in caries prevalence over the past several decades associated with increased access to dental care, heightened awareness of the benefits of early dental visits, and various fluoridation measures, caries remain prevalent in the most vulnerable groups of society: young children[1], children from low-income[2, 3] and minority backgrounds[4], and those with special healthcare needs.[5]
Dental caries continue to be the most common chronic disease of childhood[6, 7], with approximately 40% of children being affected by the time they begin kindergarten, and 78% of children having experienced decay by 17 years of age.[6] 90% of caries in the permanent dentition occur on pit-and-fissure surfaces.[1] Factors such as increased plaque retention, permeable immature enamel, and lower effectiveness of fluoride in preventing pit-and-fissure caries compared to smooth surface caries have been implicated for increased caries susceptibility at these sites.[8]
The advent of dental sealants to prevent and manage pit-and-fissure caries has greatly diminished the caries incidence in children and adolescents. For permanent molars, there is strong evidence to support that sealants are a cost effective preventive strategy, particularly in children at high risk of developing tooth decay.[8, 9] Although the current evidence supporting primary tooth sealants is based mainly on expert opinion and extrapolations from literature regarding permanent tooth sealants, the American Academy of Pediatric Dentistry (AAPD) recommends dental sealants as part of a comprehensive caries prevention plan for children over 3 years of age.[10] So, why do dental healthcare professionals choose not to seal primary teeth?
The Current Evidence
Despite over 40 years since the introduction of pit-and-fissure sealants, our profession’s use of this preventive measure has not been as extensive as the supporting scientific evidence. Data from the National Health and Nutrition Examination Survey/NHANES for the years 1999-2004 reported that the use of dental sealants on permanent teeth in children ages 6 to 11 years was only 30%.[1] Data collected by the Colorado Department of Health Care Policy and Financing and Delta Dental of Colorado show that in State Fiscal Year 2015-2016, only 18.1%[11] of Medicaid eligible children and 11.2%[12] of Colorado CHIP (CHP+) eligible children 6 to 9 years of age, have received at least one permanent molar sealant. In comparison to other developed countries, Colorado and the broader U.S. lag behind. Several northern European countries have sealant utilization rates that exceed 50%, an achievement matched by only five U.S. states.[13, 14]
Limited data exists regarding utilization of primary molar sealants. In a study assessing their cost effectiveness, Chi et al. estimated that 11% of Medicaid-enrolled children had received primary molar sealants.[15] Arguments that negate the placement of primary molar sealants suggest that the prevalence of pit-and-fissure caries in primary teeth is significantly lower than that of permanent teeth (44% vs. 90%),[1] limiting their preventive benefit. Additionally, low utilization has also been attributed to concerns that differences in the anatomy of occlusal surfaces of primary molars. These differences preclude adequate long-term retention of sealants, as well as provider apprehension about sealing over incipient and non-cavitated carious lesions.[16]
In contrast to the above arguments, a recent joint systematic review of the American Dental Association (ADA) and AAPD indicates that children who receive sealants for sound or non-cavitated pits and fissures in primary or permanent molars had a 76% risk reduction for developing new caries at a two-year follow-up compared to children without sealants.[8] At follow-ups exceeding seven or more years for these groups, it was found that children with sealants had a caries incidence as low as 29% compared to 74% in children without sealants. Furthermore, there is evidence to suggest that pit-and-fissure sealants are indeed retained on primary molars at a rate of 74%-93% at one year, and 71%-77% at three years.
Additional evidence supports sealant placement for carious primary molars as an effective measure against caries progression. In a randomized clinical trial by Hesse et al., subjects who received sealants for carious primary molars showed no statistically significant differences in caries progression when compared to subjects who received composite restorations.[17] Sealant placement may not only be caries arresting, but also alters the microbiology of the disease process by reducing bacterial levels, as suggested by a recent systematic review.[18]
Insurance: Cost vs. Benefit Analysis
One significant reason for low use of primary molar sealants is the lack of reimbursement by insurance companies. An evaluation of national data suggests that Medicaid reimburses for permanent molar sealants in every state, while only 17 state Medicaid programs do so for primary tooth sealants, excluding Colorado.[19] Ill-founded reasons for limited-to-no coverage by insurance companies for sealant placement include concerns for the cost-effectiveness, absence of guidelines, and the potential for providers to abuse usage and fees.
The study evaluating the cost-effectiveness of primary molar sealants by Chi et al. suggested that while sealing primary molars is more costly than standard care, the need for future treatment is reduced.[15] The authors advised that state Medicaid programs not currently reimbursing for primary molar sealants should consider changing their coverage policies as a population-based strategy to prevent dental caries and reduce healthcare costs. An analysis of claims data from Iowa’s Medicaid program concluded that ensuring high-risk children receive primary molar sealants would optimize cost-effectiveness.[20] Thus, evidence supports primary molar sealants in the context of a risk-based prevention strategy.
Evidence to Practice: Propagating Change
For the first time in 40 years, caries prevalence has increased in children 2-to-5 years of age, signaling the need for improved preventive strategies in this age group. The placement of dental sealants on primary molars would aid in preventing caries development and progression as well as reducing the number of cariogenic bacteria. Ideally, increasing primary molar sealant use serves to minimize multiple negative impacts including child dental pain, the growing economic burdens from treatment under general anesthesia, and deviations in growth and development.[21]
The scientific argument for primary molar sealants parallels similar conflicts between evidence-based medicine and the existing reimbursement constraints of other medical specialties. One such example pertains to the field of psychiatry, where there is strong evidence that certain non-pharmacological psychotherapies (e.g., mindfulness-based cognitive therapy) are effective when used alone for patients suffering from depression or anxiety.[22, 23] Also, such interventions appear to be beneficial when combined with medications to treat severe mental illnesses when compared to medications alone. However, psychotherapies are not reimbursed in the same manner as medications for the management of mental illnesses.
Similar to dentistry, physicians are increasingly being asked by patients and their colleagues to embrace a century where healthcare information is freely accessible and requires the provider to be current with the evidence base. Where there are clear and apparent gaps between practice and a growing body of evidence, the provider is increasingly held liable, despite reimbursement or lack thereof. In this patient care climate, the arguments to seal primary molars makes economic and evidence-based sense, but do require individual practitioners to lead a change that can impact more than just the primary dentition.
About the Authors: Dr. Camille Gannam is an assistant clinical professor in the Department of Pediatric Dentistry at Children’s Hospital Colorado and the University of Colorado School of Dental Medicine. Dr. Gannam received her dental degree from the Harvard School of Dental Medicine and completed her pediatric dentistry residency training and masters of science in dentistry from The Ohio State University and Nationwide Children’s Hospital in Columbus, OH. Dr. Roopa Gandhi serves as the residency program director and director of the Special Health Care Needs Clinic for the Department of Pediatric Dentistry at Children’s Hospital Colorado. Dr. Gandhi received her dental degree from the University of Sydney, New South Wales, Australia and completed her pediatric dentistry residency training and masters of science in dentistry from the University of Washington, Seattle, WA. She is an assistant clinical professor in the Department of Pediatric Dentistry at Children’s Hospital Colorado and the University of Colorado School of Dental Medicine.
1. Dye, B.A., et al., Trends in oral health status: United States, 1988-1994 and 1999-2004. Vital Health Stat 11, 2007(248): p. 1-92.
2. Macek, M.D., et al., Is 75 percent of dental caries really found in 25 percent of the population? J Public Health Dent, 2004. 64(1): p. 20-5.
3. Dye, B.A., O. Arevalo, and C.M. Vargas, Trends in paediatric dental caries by poverty status in the United States, 1988-1994 and 1999-2004. Int J Paediatr Dent, 2010. 20(2): p. 132-43.
4. Vargas, C.M., J.J. Crall, and D.A. Schneider, Sociodemographic distribution of pediatric dental caries: NHANES III, 1988-1994. J Am Dent Assoc, 1998. 129(9): p. 1229-38.
5. Spisak, S., et al., Improving children’s access to oral health services: the oral health initiative. Matern Child Health J, 1998. 2(4): p. 261-4.
6. Tinanoff, N. and S. Reisine, Update on early childhood caries since the Surgeon General’s Report. Acad Pediatr, 2009. 9(6): p. 396-403.
7. Oral health in America: a report of the Surgeon General. J Calif Dent Assoc, 2000. 28(9): p. 685-95.
8. Beauchamp, J., 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. Dent Clin North Am, 2009. 53(1): p. 131-47, x.
9. Wright, J.T., et al., Sealants for Preventing and Arresting Pit-and-fissure Occlusal Caries in Primary and Permanent Molars. Pediatr Dent, 2016. 38(4): p. 282-308.
10. American Academy of Pediatric, D., Guideline on caries-risk assessment and management for infants, children, and adolescents. Pediatr Dent, 2013. 35(5): p. E157-64.
11. Health First Colorado – Baseline Measures for DentaQuest as of 12/14/2016 – Project 6425.
12. Delta Dental of Colorado – CHP+ Dental Utilization Report for State Fiscal Year 2015-2016.
13. Ekstrand, K.R., S. Martignon, and M.E. Christiansen, Frequency and distribution patterns of sealants among 15-year-olds in Denmark in 2003. Community Dent Health, 2007. 24(1): p. 26-30.
14. Kallestal, C., et al., Caries-preventive methods used for children and adolescents in Denmark, Iceland, Norway and Sweden. Community Dent Oral Epidemiol, 1999. 27(2): p. 144-51.
15. Chi, D.L., D.N. van der Goes, and J.P. Ney, Cost-effectiveness of pit-and-fissure sealants on primary molars in Medicaid-enrolled children. Am J Public Health, 2014. 104(3): p. 555-61.
16. Horowitz, A.M. and P.J. Frazier, Issues in the widespread adoption of pit-and-fissure sealants. J Public Health Dent, 1982. 42(4): p. 312-23.
17. Hesse, D., et al., Sealing versus partial caries removal in primary molars: a randomized clinical trial. BMC Oral Health, 2014. 14: p. 58.
18. Oong, E.M., et al., The effect of dental sealants on bacteria levels in caries lesions: a review of the evidence. J Am Dent Assoc, 2008. 139(3): p. 271-8; quiz 357-8.
19. Chi, D.L. and J. Singh, Reimbursement rates and policies for primary molar pit-and-fissure sealants across state Medicaid programs. J Am Dent Assoc, 2013. 144(11): p. 1272-8.
20. Ney, J.P., D.N. van der Goes, and D.L. Chi, Economic modeling of sealing primary molars using a “value of information” approach. J Dent Res, 2014. 93(9): p. 876-81.
21. Casamassimo, P.S., et al., Beyond the dmft: the human and economic cost of early childhood caries. J Am Dent Assoc, 2009. 140(6): p. 650-7.
22. Grossman, P., et al., Mindfulness-based stress reduction and health benefits. A meta-analysis. J Psychosom Res, 2004. 57(1): p. 35-43.
23. Noordali, F., J. Cumming, and J.L. Thompson, Effectiveness of Mindfulness-based interventions on physiological and psychological complications in adults with diabetes: A systematic review. J Health Psychol, 2015.
Figure borrowed from Chi, D.L., D.N. van der Goes, and J.P. Ney, Cost-effectiveness of pit-and-fissure sealants on primary molars in Medicaid-enrolled children. Am J Public Health, 2014. 104(3): p. 555-61.