It is important to define the target population for the school-based dental sealant program. Using a population-based approach, where schools with a high concentration of students at high risk for dental caries are targeted, will maximize the program’s impact. Needs-assessment results can help define the target population.
Recommendations contained in the article, Workshop on Guidelines for Sealant Use: Preface and Recommendations, provide step-by-step instructions for selecting approaches to increase dental sealant prevalence.5 The planning committee should consult these recommendations when deciding whether school-based dental sealant programs are appropriate for specific population groups.
Another helpful resource in defining the target population is The Association of State and Territorial Directors' Best Practices Approach: School-Based Dental Sealant Programs, which includes information on surveillance systems and school-based dental sealant programs.
National data indicate that children from families with low income are at greater risk for tooth decay compared to their more affluent counterparts. As a result, many school-based dental sealant programs use income as a basis for targeting schools.6 Two federal programs that are commonly used as proxies for income, barriers to accessing oral health care, and increased risk for tooth decay are the U.S. Department of Agriculture’s (USDA’s) National School Lunch Program (NSLP) and Title I, Part A, of the Elementary and Secondary Education Act.
USDA's NSLP provides free or reduced-price meals to students whose families meet income eligibility guidelines. School-based dental sealant programs frequently target schools in which at least 50 percent of students qualify for USDA’s free or reduced-price meals.
Targeting Title I schools is also an income-based approach that many school-based dental sealant programs use to identify schools. The U.S. Department of Education provides financial assistance to local educational agencies and schools with at least 40 percent of student enrollment made up of children from families with low incomes to ensure that all children and adolescents meet state academic standards.7
NSLP and Title I programs are usually administered by state departments of education, which operate the programs through agreements with school food authorities.
When using income as a method of targeting schools for a school-based dental sealant program, it is important to consider differences between urban and rural areas in the geographic distribution of families with low incomes.
In urban areas, families with low incomes tend to cluster in neighborhoods. As a result, schools near or in these neighborhoods frequently have high percentages of students from families with low incomes.
In rural areas, families with low incomes tend to be spread more evenly throughout the school system. While large numbers of families with low incomes may reside in a rural county, it can be unlikely that schools in that county will have particularly high percentages of students from families with low incomes. When this situation exists, some statewide dental sealant programs target rural areas using median family incomes and then include all schools in a school system in which median family income is below a certain level.
Once schools have been selected for inclusion in the school-based dental sealant program, a decision needs to be made about which students at the school are eligible for the program. Possibilities include
In some instances, schools prefer not to target specific students because of the potential for stigmatizing those selected for the school-based dental sealant program or because the school philosophy supports providing services to all students. In these cases, programs make dental sealants available to all students in targeted grades.
Other school-based dental sealant programs make all students in the target schools eligible to receive dental sealants because of high mobility rates among students from families with low incomes, especially those living in urban areas.8
Some communities have large numbers of immigrants, refugees, or undocumented individuals. Students from these groups are eligible to receive public education but may not qualify for USDA’s free or reduced-price meals. Flexibility should be built into eligibility criteria so that these groups are not excluded from school-based dental sealant programs. Many times, these populations have the greatest oral health needs.
Pit-and-fissure decay is most likely to occur in first and second molars.9 Therefore, it is recommended that school-based dental sealant programs target these teeth.10
Second grade seems to be the most appropriate grade during which to seal the most erupted, noncarious first molars.11 Table 1 shows the likelihood of the occlusal surfaces of first and second molars being sufficiently erupted for dental sealant application at different grade levels. The eruption time of the second molars, however, is quite variable; they usually erupt when a student is between sixth and eighth grades.
Table 1: Availability for Dental Sealant Application of Occlusal Surfaces of First and Second Permanent Molar Teeth, According to Grade Level, Ohio 1987–1988
Percentage of Students with All Four Occlusal Surfaces Sufficiently Erupted for Dental Sealant Application and with No Occlusal Surfaces Sufficiently Erupted +
First Permanent Molars |
Second Permanent Molars |
|||
Grade Level |
All Four % |
None % |
All Four % |
None % |
1 |
57.2 |
18.8 |
||
2 |
88.5 |
1.8 |
||
3 |
96.8 |
0.0 |
||
6 |
23.6 |
37.6 |
||
7 |
55.5 |
11.8 |
||
8 |
75.8 |
3.6 |
||
+”Sufficiently erupted” means that the occlusal surface is completely exposed and clear of gingival tissue, but the term does not indicate eruption status of buccal and lingual surfaces with pits and fissures, which can contribute to overall caries levels.
Adapted, with permission, from Kuthy, RA, Ashton, JJ. 1989. Eruption pattern of permanent molars: Implications for school-based dental sealant programs. Journal of Public Health Dentistry 49(1):7–14.
For a school-based dental sealant program to operate as efficiently as possible, when identifying what grade or age group to target, it is important to consider output in relation to effort, the number of eligible teeth to be sealed, the likelihood that students will participate in the program, and available resources. The following factors should be considered:
After considering these factors, many school-based dental sealant programs choose to target students in both second grade and sixth grade. Those that target students in higher grades find that, while a higher percentage of second permanent molars have erupted among this age group, fewer students participate in the program. Participation rates vary among programs, but the pattern of participation by grade is consistent. Students in second grade are far more likely to participate than students in sixth, seventh, and eighth grades. The participation rate for students in sixth grade is usually 10–15 percentage points lower than that of students in second grade, and the rate for students in seventh and eighth grades is usually 15–20 percentage points lower than that for students in sixth grade.
