Seal America, The Prevention Invention
Seal America, The Prevention Invention

Step 8
Implementing the Program

The efficiency of a school-based dental sealant program is highly dependent upon the preparations that are made before the dental equipment is delivered to the school. Programs make a variety of arrangements for transporting equipment. In some cases, staff use their own personal vehicles. When the school-based dental sealant program is sponsored by an agency, staff or school personnel might use agency-owned vans.

Program Setup

Equipment and supplies need to be well organized so they can be unpacked and transformed into dental operatories quickly. In programs with two or more dental hygienist and assistant teams, dental assistants may have their own supplies and equipment, which they are responsible for maintaining. Storage containers should have labels identifying their contents and the team to which they belong so the supplies and equipment can be easily sorted on the day the equipment is delivered.

Figure 8.1. Van Loaded with Equipment

Figure 8.1. Van Loaded with Equipment. Courtesy of the Cincinnati Department of Health.

Either on the day before the program is scheduled to begin, or early in the morning on the same day, dental equipment should be delivered to the school and placed in the area where the program will operate. All equipment setup and breakdown, sterilization, instrument-tray preparation, and paperwork should occur before or after school.

The setup process involves creating dental treatment areas and a sterilization area. Before the dental operatories are erected, the assistants locate the electrical outlets and determine where each operatory will be placed. Each dental assistant has equipment and supplies for one treatment area, and they begin by separating equipment into groups. As they are setting up the treatment area, dental assistants strategically locate supplies around the dental operatory so that the supplies are within reach. Storage containers, which are used to transport supplies, can double as tables. A large trash can, if lined with plastic, can be used to transport supplies, and then later be used as the trash receptacle. Tray tables can be set up on either side of the dental operatory, so that the dental hygienist uses one table to hold student records and parent notes and referrals (which the hygienist completes after applying sealants for each student) and the dental assistant uses one table to hold extra disposable supplies and sealant materials.

Containers placed behind the dental assistant can hold prepared instrument trays, hand wipes, toothbrushes, foil wraps for the dental lights, disposable sunglasses for eye protection, sandwich bags for toothbrushes, and extra supplies that may be needed as the day progresses. A storage container beside the dental hygienist can hold gloves, masks, and hand wipes. A dishpan placed under the tray table next to the dental assistant can be used as a receptacle for contaminated instruments used to place dental sealants.

The sterilization area is a common, shared area and should be set up near the treatment area. It is important to identify and maintain a clean side and a dirty side within the sterilization area. Equipment and supplies normally include a sterilizer, an ultrasonic cleaner, containers with rinse water, sterilizer bags, paper towels, and gloves. Extra supplies needed for sterilization may be stored under the sterilization table or in another convenient, clean location.

Another area should be reserved for extra supplies, backup equipment, and empty bags and containers. This area should be easily accessible so the supplies and equipment can be retrieved as needed.

While the dental assistants are preparing the operatories, the dental hygienist(s) can check to see if any signed parental consent forms were returned to the school since the forms were collected. The student health histories also need to be reviewed, if necessary, and, for students who do not have records, student records need to be prepared.

Figure 8.2. An Operatory Set Up and Ready for Students.

Figure 8.2. An Operatory Set Up and Ready for Students. Courtesy of the Cincinnati Health Department.


  1. Dental chair
  2. Dental hygienist stool
  3. Dental assistant stool
  4. Light
  5. Tray table with student records, parent notes, and gloves
  6. Dental unit
  7. Prepared instrument tray
  8. Tray table with sealant mixing supplies and extra paper supplies
  9. Air compressor
  10. Dishpan for disposing of used non-disposable instruments
 
  1. Storage crate with disposable sunglasses, toothbrushes, sandwich bags, and gloves

  2. Storage crate with prepared instrument trays

  3. Storage crate with foil wraps, hand wipes, and headrest covers

  4. Storage crate for miscellaneous supplies used throughout the day

  5. Trash can

  6. Chair for student waiting to have sealants applied

  7. Sterilization table

  8. Ultrasonic cleaner

  9. Steam-under-pressure sterilizer

  10. Sterilization and disinfection supplies


[Back to Top]

Student Assessments

Organizing and Conducting Assessments

Student assessments determine the need for dental sealants. In some programs, assessments are performed before the program starts so that program administrators know ahead of time how many students need sealants. Other programs conduct assessments on the same days that sealants are applied.

When feasible, in cases where assessments are conducted while the program is under way, dentists should be scheduled to conduct assessments on the first 2 days at each school, even if the assessments could be completed in a single day. Having the dentist available on 2 days helps increase participation by allowing assessment of additional students who were absent on the first day. Also, some students decide they would like to participate in the program after seeing their classmates participate. Having the dentist available on the second day allows students who take forms home on the first day and return signed consent forms the next day to receive assessments.

Assuming that assessments were not conducted on an earlier date, the first assessment should be under way 15 minutes after school starts on the first day of the program. To make sure the program begins on schedule, shortly after school begins, a dental assistant goes to the first classroom of students who are to receive dental sealants, confirms that the teacher knows how the program works, and gathers all the students in the class who returned signed consent forms. The dental assistant hands students their own records and escorts them to the assessment area.

In the assessment area, the students line up, and the dentist assesses them, normally at a rate of 45 to 50 students per hour. The dentist first verifies that students are matched with the correct record by addressing each student by name and asking the student his or her birthdate.

Meanwhile, the dental hygienist places a headrest cover on the dental chair (paper towel squares are an excellent substitute for headrest covers, as they are easier to change and less expensive). The first student sits in the dental chair to be assessed. During the assessment, the dentist calls aloud the results, including which teeth need dental sealants and which teeth or surfaces are decayed, missing, or filled. The dentist deposits used instruments into containers on the floor and throws disposable gloves in a nearby trash can. The dental hygienist records the findings on the student’s chart, which is then placed in the student record.

Afterward, the student is either sent back to class (to be called back later for sealant placement) or kept to receive sealants, and the next student moves to the first chair to be assessed. Since conducting assessments take less time than applying sealants, most students return to class after being assessed and are called back for sealant placement. If two operatories with two teams are set up in one school, the second team can begin placing dental sealants as soon as the first student is assessed.

Student Flow Diagram for Sealant Assessments

Courtesy of the Cincinnati Health Department


The student’s name and all demographic information should be recorded in the student record before assessments begin. The following information is recorded in student charts during the assessment:

  • Assessment date
  • Caries history
  • Presence and location of untreated caries
  • Dentist code and signature
  • Presence and location of existing dental sealants
  • Location where dental sealants need to be placed
  • Any notes concerning the student’s behavior or specific health considerations or dental needs

After each student’s assessment is complete, the student may be given a reward (e.g., a pencil, a sticker) for participating in the program before they return to their classroom.

Figure 8.3. Two Operatories Set Up and Ready for Students.

Figure 8.3. Two Operatories Set Up and Ready

As soon as all assessments are completed for the day or half day, the dentist signs the student charts. The dental hygienist organizes student records by classroom and separates the records of students who do not need dental sealants. Records can also be separated into two categories: students who require referral and students who do not. Step 9, Referral and Follow-up, provides additional information about referral. Meanwhile, the dental assistant prepares the assessment instruments for sterilization and the dental operatory for sealant application. If the assessments are conducted for half a day, the dental hygienist and assistant can use the remaining half day to apply dental sealants.

Indications for Sealant Placement

The CDC convened two meetings of a work group consisting of experts in dental sealant research practice and policy, as well as caries assessment, prevention, and treatment. The workgroup also included representatives from professional dental organizations. In November 2009, the work group released recommendations on the use of dental sealant programs in school-based settings. These recommendations included the following guidelines on tooth-surface assessment and indications for sealant placement. Table 8.1 outlines guidelines for tooth surface assessment.

Table 8.1. Guidelines for Tooth Surface Assessment

Differentiate Between Cavitated and Noncavitated Lesions
  • Unaided visual assessment is appropriate and adequate.
  • Dry teeth before assessment with cotton rolls, gauze, or, when available, compressed air.
  • An explorer may be used to gently confirm cavitations (that is, breaks in the continuity of the surface); do not us a sharp explorer under force.
  • X-rays are unnecessary for sealant placement only.
  • Other diagnostic technologies are not required.

 

Source: Gooch BF, Griffin SO, Gray SK, Kohn WG, Rozier RG, Siegal M, Fontana M, Brunson D, Carter N, Curtis DK, Donly KJ, Haering H, Hill LF, Hinson HP, Kumar J, Lampiris L, Mallat M, Meyer DM, Miller WR, Sanzi-Schaedel SM, Simonsen R, Truman BI, Zero DT; Centers for Disease Control and Prevention. 2009. Preventing dental caries through school-based dental sealant programs: Updated recommendations and reviews of evidence. Journal of the American Dental Association 140(11):1356–1365. http://jada.ada.org/content/140/11/1356.full.

Table 8.2 outlines the indications for dental sealant placement on teeth that are sufficiently erupted for sealant application.

Table 8.2. Indications for Placement of Dental Sealants

Tooth Status Indications for Sealants
Caries-free teeth Seal
Non-cavitated carious lesions Seal
Teeth with cavitated lesions with no visual signs of dentinal caries Do not seal; refer for treatment. (If the student is unlikely to receive prompt treatment, dental sealants may be placed as an interim measure.)
Teeth with cavitated carious lesions Do not seal; refer for treatment. (If the student is unlikely to receive prompt treatment, atraumatic restorative treatment may be delivered if it is within the dental team member’s scope of practice.)

 

Source: Gooch BF, Griffin SO, Gray SK, Kohn WG, Rozier RG, Siegal M, Fontana M, Brunson D, Carter N, Curtis DK, Donly KJ, Haering H, Hill LF, Hinson HP, Kumar J, Lampiris L, Mallat M, Meyer DM, Miller WR, Sanzi-Schaedel SM, Simonsen R, Truman BI, Zero DT; Centers for Disease Control and Prevention. 2009. Preventing dental caries through school-based dental sealant programs: Updated recommendations and reviews of evidence. Journal of the American Dental Association 140(11):1356–1365. http://jada.ada.org/content/140/11/1356.full.

Fully erupted molars can be sealed. Partially erupted molars can also be sealed if the surfaces can be isolated and kept dry during application. Buccal and lingual surfaces with deep pits and grooves can be sealed as well.

[Back to Top]

Student Flow During Sealant Placement

To maintain student flow and ensure that staff do not have to wait for students to report to the sealant program to receive their sealants, each dental assistant and hygienist team should strive to have one student in the dental chair receiving sealants and a second student waiting. Waiting students are given dry toothbrushes to brush their teeth. After the dental hygienist seats a student in the dental chair, the teeth are checked for cleanliness and re-brushed (with the same dry toothbrush that the student used previously) if necessary. The student’s toothbrush is placed in a plastic bag and given to him or her to keep.

As soon as one student has received sealants, the dental hygienist completes a note to the parent and (if needed) a referral for follow-up care, gives the note to the student to take home, and sends that student back to class. The student returning to the classroom can send another student to the area where sealants are being applied. At the same time, the dental assistant places the contaminated instruments in a dishpan located on the floor and places disposable products in the trash can. The assistant disinfects the dental operatory, retrieves a new instrument tray, and instructs the waiting student to sit in the chair.

Patient Flow Diagram

Courtesy of the Cincinnati Health Department

Technique

The technique used to apply dental sealants varies depending upon the type of sealant material used (see Selecting Dental Sealant Materials in Step 4, Purchasing Dental Equipment and Supplies). Using self-curing sealant material under ideal conditions, a half-mouth of sealants (two to eight sealants) can be applied from one mix of sealant material, with all the sealants curing in about 1 minute. Cooler temperatures slow curing time, and warmer temperatures accelerate it. While the setting time of light-cured sealant can be controlled, each tooth has to be individually cured, which takes more time.

Technique also varies depending upon the type of isolation used. Cotton rolls with and without cotton roll holders and dry angles are usually used. While cotton roll holders may seem cumbersome at first, most dental hygienists and assistants become accustomed to using them and eventually find that they make it easier to maintain a dry environment. Cotton roll holders are particularly important when sealing a half mouth at a time. Most teams who do not use cotton roll holders seal a quadrant at a time.

Before dental sealants are applied, be sure to read the manufacturer’s instructions carefully, since different brands of sealants may require slightly different application techniques. The basic procedure for applying sealants is as follows:

Step 1. Thoroughly clean teeth to be sealed
Step 2. Isolate the teeth
Step 3. Etch tooth surface
Step 4. Rinse and dry
Step 5. Place sealants
Step 6. Polymerize sealants
Step 7. Inspect sealants

Figure 8.5. Thoroughly Clean Teeth.

Figure 8.5. Thoroughly Clean Teeth. Courtesy of William F. Waggoner, D.M.D., M.S.

Figure 8.6. Place Cotton Rollers.

Figure 8.6. Place Cotton Rollers. Courtesy of William F. Waggoner, D.M.D., M.S.

Figure 8.7. Acid Etch

Figure 8.7. Acid Etch. Reproduced, with permission, from Waggoner WF, Siegal M. 1996. Pit and fissure sealant application: Updating the technique. Journal of the American Dental Association 127:351–361. Copyright ©1996 American Dental Association.

Figure 8.8. Etched Tooth Has a Frosty Appearance

Figure 8.8. Etched Tooth Has a Frosty Appearance. Reproduced, with permission, from Waggoner WF, Siegal M. 1996. Pit and fissure sealant application: Updating the technique. Journal of the American Dental Association 127:351–361. Copyright ©1996 American Dental Association.

Figure 8.9. Place Sealants

Figure 8.9. Place Sealants. Courtesy of William F. Waggoner, D.M.D., M.S.

Figure 8.10. Inspect Sealants

Figure 8.10. Inspect Sealants. Courtesy of William F. Waggoner, D.M.D., M.S.

Step 1. Thoroughly Clean Teeth to Be Sealed
Sealant programs have achieved satisfactory retention rates using a dry toothbrush to remove any debris that may remain on the teeth after the student has brushed. The teeth are thoroughly rinsed before they are isolated.

Step 2. Isolate the Teeth
Effective saliva control can be achieved by positioning the student so that the teeth to be sealed are visible and accessible. The student’s head can be tilted so that saliva pools on the opposite side of the mouth from the side with teeth being sealed. A high-volume evacuator should be used. Cotton rolls or cotton roll holders and dry angles should be positioned as desired. Dry angles are most effective if placed over the parotid duct opening. Some teams like to place a dry angle between the cotton roll holder and the lingual surface of the mandibular teeth to create an additional barrier for the tongue. Once the cotton rolls are in place, the teeth should be thoroughly dried.

Step 3. Etch Tooth Surface
The cleaned and dried tooth surfaces are etched with phosphoric acid for at least 20 seconds. A small cotton pellet, mini-sponge, or brush can be used to apply the etchant. Etchants are available in liquid and gel form. The type used is a matter of personal preference. Acid should be placed widely over the enamel surface so there is no chance that the sealant margin is placed on un-etched enamel. The most common error is to limit the acid to the pits and fissures. If the acid inadvertently comes in contact with soft tissue, it needs to be rinsed immediately and thoroughly.

Step 4. Rinse and Dry
After 20 seconds, the etchant is thoroughly rinsed off the teeth. It is critical that saliva not come into contact with the prepared tooth surfaces during this step. Excess moisture is removed with the high-speed evacuator. Sometimes dry cotton rolls or dry angles are placed over the moist ones to maintain a dry field. When dry, a properly etched surface will have a dull matte or frosty appearance, in contrast to the glossy appearance of un-etched enamel. Should salivary contamination occur after this point, the surface must be washed, dried, re-etched for 10 seconds, and washed and dried again before the next sealant-application step.

Step 5. Place Sealants
Since the application step will vary according to the product selected, the dental hygienist should follow the manufacturer’s instructions. When a self-cured material is used, the liquid catalyst and base are mixed in a 1:1 ratio. The student’s head should be positioned so that the occlusal plane is parallel to the floor so the sealant does not flow distally before it cures, leaving the mesial pits underfilled. Using the applicator provided by the manufacturer, the mixed sealant is flowed over the etched, dried surface. The sealant should be placed into the fissured surface, flowing from one end of the fissure carefully through the fissure complex to avoid air bubbles, and covering only the fissures and a small area of the fissure walls. If more than one tooth in a quadrant is being sealed, the most posterior tooth should be treated first, since maintaining dryness is more difficult in the back of the mouth.

Step 6. Polymerize Sealants
If using light-cured sealants, it is important that the curing light is set at the correct intensity and that the manufacturer’s instructions on the length of time the sealant should be exposed to the curing light are followed. With autopolymerized sealants, sufficient time must be allowed so that the depth of the polymerization reaches the tooth surface under the sealant.

Step 7. Inspect Sealants
Isolation of the teeth should be maintained until the dental sealants are checked visually and with an explorer to make sure coverage of the pits or fissures is complete. If there is a surface air bubble, more sealant can be applied if the tooth has remained uncontaminated. Otherwise, the tooth must be re-etched for 10 seconds, washed, and dried before adding sealant material. A thin surface film of sealant will remain unpolymerized because of contact with air. This film has an unpleasant taste and should be wiped off with a wet cotton roll. The isolation materials can then be removed, and the student may be allowed to rinse. The students should be told that the sealants may feel “high” but that the student’s own teeth will wear it down during the next few days.

If bonding agents are used, an additional step needs to be added between steps 5 and 6 in the sealant placement process. Once the tooth surface has been etched and thoroughly dried, the bonding agent should be placed on the tooth, and the agent should be air thinned before the sealant is applied. This steps helps the sealant material flow into the deep fissures, helps bonding in areas of inadvertent moisture contamination, and improves sealant retention.2

References

  1. Gooch BF, Griffin SO, Gray SK, Kohn WG, Rozier RG, Siegal M, Fontana M, Brunson D, Carter N, Curtis DK, Donly KJ, Haering H, Hill LF, Hinson HP, Kumar J, Lampiris L, Mallat M, Meyer DM, Miller WR, Sanzi-Schaedel SM, Simonsen R, Truman BI, Zero DT; Centers for Disease Control and Prevention. 2009. Preventing dental caries through school-based dental sealant programs: Updated recommendations and reviews of evidence. Journal of the American Dental Association 140(11):1356–1365. http://jada.ada.org/content/140/11/1356.full.
  1. Feigal RJ. 2004. Making the most of sealant usage. Dimensions of Dental Hygiene 2(7):18–20. http://www.dimensionsofdentalhygiene.com/ddhright.aspx?id=227.

 

[Back to Top]

 

Home Acknowledgments FAQ's