Module 5: Operating Effective Programs
+ Show Module Chapters

Please Note: This curriculum was developed prior to the COVID-19 pandemic and may not reflect current guidance for materials, procedures, and infection control.

Image of girl in chair

5.1 Effective Program Operations

To be effective, school-based dental sealant programs must:

  • Provide high-quality dental sealants with good retention rates.
  • Serve children at higher risk for dental caries.
  • Apply sealants efficiently, so that as many children as possible receive sealants.
Figure 1. Percent of Ohio Third Graders with Untreated Caries at Higher-Risk Schools Versus Lower-Risk Schools by Risk Threshold, 2004–2005
Figure 1. Percent of Ohio Third Graders with Untreated Caries at Higher-Risk Schools Versus Lower-Risk Schools by Risk Threshold, 2004–2005

In addition, most effective programs have the support of key constituencies in their communities (e.g., school administrators, school nurses, dentists). Seal America: The Prevention Invention (3rd ed.) and the Report of the Sealant Work Group: Recommendations and Products provide useful information on how to obtain such support.

Targeting Populations

Targeting Schools

For school-based dental sealant programs, the objective of targeting is to provide sealants to the largest possible number of children at high risk for dental caries. Targeting programs to populations has been shown to be more cost-effective1 than targeting them to specific children based on oral health status, and the former is easier to implement.2 National data show that, compared with children from families with higher incomes, children from families with low incomes are at higher risk for experiencing dental caries and for having untreated caries,3,4 are less likely to have sealants,3 and are less likely to have a dental visit in a year.5

During the 2004–2005 school year in Ohio, children in third grade who were at high risk for dental caries and who attended schools with sealant programs were more than twice as likely to have sealants as their counterparts at schools with no programs (59 percent vs. 29 percent). The school-eligibility threshold at that time was > 50 percent student enrollment in the Free and Reduced Price Meals program (FRPM)a.6

Figure 2. Number of Higher-Risk Schools and Average Number of Higher-Risk Ohio Third Graders per School by Risk Threshold, 2004–2005
Figure 2. Number of Higher-Risk Schools and Average Number of Higher-Risk Ohio Third Graders per School by Risk Threshold, 2004–2005

ODH considers almost half (48 percent) of all children in the surveyed grade who attend public schools in Ohio to be at higher risk based on either FRPM enrollment, Medicaid enrollment, or the fact that they are uninsured and have not had a dental visit within a year. ODH compared the effects of various school-eligibility thresholds (i.e., > 60 percent of children enrolled in FRPM, > 50 percent enrolled, > 40 percent enrolled, > 30 percent enrolled) on oral health status and the number of children at higher risk per school. Figure 1 shows that for all the thresholds considered, children at schools with higher FRPM enrollment were significantly more likely to have dental caries than children at schools with lower enrollment. Figure 2, however, shows that the number of children per school who are at higher risk drops significantly when less than 40 percent of students at the school are enrolled in FRPM.7

Because of these findings, ODH revised the school-based dental sealant program-eligibility criteria for ODH-funded programs as follows:

School-based dental sealant programs target schools in which 40 percent or more of the children are enrolled in FRPM. Schools in which 40 to 49 percent of children are enrolled in FRPM may be served at any time during the year, if the program assures the ODH Oral Health Section (OHS) that all schools with > 50 percent enrolled in FRPM will be served during the year. Without that assurance, a program can visit only schools with 40–49 percent of children eligible for FRPM after all schools with > 50 percent of children enrolled in FRPM have been served.

Targeting Children in Specific Grades

School-based dental sealant programs in some eligible schools target children in specific grades (typically grades 2 and 6) to provide sealants for vulnerable, newly erupted permanent molars. With ODH approval, programs may target other grades (e.g., grade 7, with grade 8 follow-up, to seal more newly erupted second molars).

Follow-up in grades 3 and 7 serves two purposes: (1) screening for sealant retention and sealant repair or replacement, if needed, and (2) sealing previously unerupted molars.

Efficient Program Operations

The efficiency of a program depends on the extent to which planning takes place before the sealant team arrives at a school, as well as on staff mindset, which must be oriented toward working as efficiently as possible. Making a program more efficient results in more children (e.g., 20 vs. 10) receiving sealants each day, which in turn leads to completing a school in fewer days and serving more schools during a school year. Efficient operations also translate into lower per-child costs for providing sealants.

Steps that programs can take to increase efficiency

  • Collect consent forms 1–2 weeks in advance of the date on which sealants will be placed to allow time for health histories to be screened and charts to be prepared.
  • Check with school personnel (e.g., principal, nurse, teacher, secretary) to make sure there are no scheduled field trips, tests, special guests, parties, or other events that could interfere with sealant screening or placement.
  • Set up the operatory and support area before the start of the school day. Start seeing students as soon as possible once school begins, and continue until dismissal. Working partial days reduces efficiency because the time needed for travel and for equipment set-up and break-down is the same as for a full day, but the number of children who receive sealants is lower.
  • Have a line of children ready to be screened to determine their need for sealants (30–45 children per hour).
  • Always have one child in the chair receiving sealants and one child waiting for his or her turn (see Step 8 of Seal America: The Prevention Invention (3rd ed.), for information on how to efficiently set up the work area and manage patient flow for screenings and sealant placement).
  • Give the child who is waiting for sealants a dry toothbrush, and ask the child to brush his or her back teeth. Place the brush in a sealed plastic bag for the child to keep. After applying sealants, send the child back to class with the name of another child who should come to receive sealants.
  • Use auto-polymerized sealant material. Under ideal conditions, a half-mouth of sealants (two to four sealants) can be applied from one mix of sealant material, with all the sealants curing in about 1 minute. Cooler temperatures slow the curing time, and warmer temperatures accelerate it. Light-cured sealant material requires curing each tooth individually, which takes more time and may result in fewer children receiving sealants over the course of a school day. For more information on auto-polymerized sealant materials, see Sealant Materials.
  • Use cotton roll holders to 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, which is more time consuming.
  • In programs covering large geographic areas, coordinate scheduling of schools that are near each other, if practical. School schedules (e.g., lunch times) may dictate the feasibility of this approach.


a. Throughout this module, “Free and Reduced Price Meals program” refers to the National School Lunch Program, a federally assisted meal program operating in public and nonprofit private schools and residential child care institutions. It provides nutritionally balanced, low-cost, or free lunches to children each school day.