Getting Started

Getting Started

Target Population

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 increased risk for tooth decay are targeted, will maximize the oral health of as many students as possible in a catchment area. Needs-assessment results can help define the target population.

Recommendations contained in the report, Workshop on Guidelines for Sealant Use: Preface and Recommendations, provide step-by-step instructions for selecting approaches to increase dental sealant prevalence.3 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 ASTDD’s Proven and Promising Best Practices for State and Community Oral Health Programs, which includes information on surveillance systems and school-based dental sealant programs.4

Income Level

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. 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 National School Lunch Program and Title I, Part A, of the Elementary and Secondary Education Act.

The U.S. Department of Agriculture’s (USDA’s) National School Lunch Program (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.5

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.6

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.

Students Eligible for the Program

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

  • All students
  • Students who qualify for USDA’s free or reduced-price meals
  • Students who do not have a dental home
  • Students who are enrolled in or eligible for Medicaid or the Children’s Health Insurance Program (CHIP)
  • Students who do not have dental insurance
  • Students who must travel long distances to dental practices or clinics

In some instances, schools are unwilling to single out 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.

Some communities have large numbers of immigrants, refugees, or undocumented individuals. Children 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 need.

School Grade

Pit-and-fissure decay is most likely to occur in first and second molars.7 Therefore, it is recommended that school-based dental sealant programs target these teeth.8

Second grade seems to be the most appropriate grade during which to seal the most erupted, noncarious first molars.9 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 %



















+”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 Dentistry49(1):7–14.

Wisconsin’s Seal-A-Smile program targets all students in schools because of the high mobility rates among children from families with low incomes, and especially those living in urban areas. Program data show little variability between the numbers of students in grades 1 through 5 who received dental sealants. Other preventive services are provided if sealants do not need to be placed.

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 take into account output in relation to effort, considering 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:

  • Tooth-eruption rates. Many programs target only students in second grade, because rates of erupted, non-carious teeth tend to be greater than for students in either first grade or higher grades. Less than 60 percent of all first molars of students in first grade are fully erupted. The probability of all four first molars being fully erupted among students in third grade is high (89 percent to 97 percent); however, the possibility of those teeth having decay is higher than among students in lower grades. Targeting students in higher grades (grades 6, 7, or 8) can be more difficult because the age by which all four second molars have erupted varies widely.
  • Susceptibility. Looking at caries prevalence over time based on tooth type, permanent first and second molars are more susceptible to tooth decay than other tooth types (e.g., canines, premolars, incisors).7
  • Risk. Children and adolescents ages 6 to 19 from families with low incomes are twice as likely to have untreated tooth decay as are their counterparts from families with higher incomes.10 Because erupting molars are more likely to develop decay in children living in communities without water fluoridation, programs might target schools with non-fluoridated water supplies earlier in the school year than they would schools with fluoridated water supplies.
  • Participation rates. Students’ participation rates tend to be lower in middle school and high school than in elementary school, leaving second molars vulnerable to decay. Extra effort and creative approaches may be needed to overcome failure to return signed consent forms, peer pressure, and fear of dentistry, which are all potential reasons for low rates of participation.
  • School structure. When targeted grades are in the same building, it is more efficient to reach students for dental sealant placement as well as to conduct follow-up assessment. Some school systems offer kindergarten through grade 8, while others offer kindergarten through grade 5, with middle school offering grades 6 through 8 and high school offering grades 9 through 12. Some school systems, on the other hand, include schools that are divided into a small number of grades (e.g., kindergarten through grade 3, grades 4–6, grades 7–8, grades 9–12). This organizational structure makes it difficult to target students in grades 6–8.
  • Class schedules. It can be challenging to implement dental sealant programs in schools where each student has an individual schedule and moves from classroom to classroom throughout the day. However, many school-based dental sealant programs have found creative ways to address the problem, such as drawing students from study hall or other non-academic classes to apply sealants.

After considering these factors, many school-based dental sealant programs choose to target students in both sixth grade and second 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 by far the best participators. School-based dental sealant program compared participation rates by grade levels and determined that 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 15–20 percentage points lower than that for students in sixth grade.11