DentalSealants:ProventoPreventToothDecay

ALookatIssuesImpactingtheDeliveryofStateandLocalSchool‐BasedSealantPrograms

May2014

TheChildren’sDentalHealthProject(CDHP)extendsdeepthankstoallwhoprovidedinformation,dataandtechnicalreviewofthisreport,includingstatepublichealthdentalleaders,theCentersforDiseaseControlandPrevention,CentersforMedicareandMedicaidServices,AssociationofStateandTerritorialDentalDirectorsandtheHealthResourcesandServicesAdministration.CDHPisanindependentnonprofitbasedinWashington,D.C.CDHPworkstoimproveoralhealthforchildrenandfamiliesbyidentifyingandadvancingsolutionsthatareinnovativeandcost‐effective.CDHPpromotesstrategiesthataregroundedinthebestavailableresearchandwhereevidenceislacking,leadseffortstoexplorenewapproaches.Tolearnmore,visitwww.cdhp.org.  

  

Note:MaterialsforthisprojectwerepreparedbytheChildren’sDentalHealthProjectandconsultants.ThereportwassupportedbyCentersforDiseaseControlandPreventionCooperativeAgreementNo.5U58DP002285‐04totheChildren’sDentalHealthProject.ItscontentsaresolelytheresponsibilityoftheauthorsanddonotnecessarilyrepresentofficialCDCviews.

TableofContents

Methods……………………………………………………………………………………………….1

Findings……………………………………………………………...........................................4

Featuresof5StateswithSustainableandSubstantialSchoolSealantPrograms(SSPs)…………………………..……………………………..11KeystoSuccessforSustainableandSubstantialSSPs……..………………….14

TranslatingLessonsLearnedintoPractice…..…………………………………….17

Conclusion……………………..…………………………………………………………………..20

1

chool‐baseddentalsealantdeliveryprogramsareanevidence‐

basedpublichealthstrategyforpreventingtoothdecayamong

school‐agedchildren,particularlythoseathighestrisk.1Dental

sealantsareprotectivecoatings,generallyappliedtochildren’spermanent

teeth,whichhavebeenshowntoreducetoothdecayby60percent.2The

CommunityPreventiveServicesTaskForcerecommendsschool‐based

sealantdeliveryprograms,reflectingevidencethattheseprograms

“increasethenumberofchildrenwhoreceivesealants…andthatdental

sealantsresultinalargereductionintoothdecayamongschool‐aged

children(5to16yearsofage).”3

Thisreportprovidesanoverviewoftheprogramdesignandkeyissuesin

school‐baseddentalsealantprogramsintheU.S.Itoffersexamplesoffactorsthat

mayfacilitateorcomplicateprogramfinancing,reach,andsustainability.It

considersfeaturesoffivestates—IL,NY,OH,SC,andWI—thathavehad

longstandingschoolsealantprogramsandexplorescurrentandpotentialchallenges

forimplementingsuchprograms.Finally,thereportprovidesrecommendationsfor

allwhoareengagedinpromotingchildren’soralhealththroughschoolsealant

programs(SSPs).

Informationforthisreportwasobtainedbetween2011and2013andincluded

surveysofstateoralhealthofficialsandselectSSPprogramofficials,qualitative

structuredinterviews,andin‐depthcasestudies,allconductedunderacooperative

agreementbetweentheChildren’sDentalHealthProjectandtheCentersforDisease

ControlandPrevention.

METHODS

Thisprojectdefinedstateswith“sustained”school‐basedsealantprogramsas

havingoneormoreSSPoperatingeachyearfor10years(2003—2012),asself‐

reportedbystatesintheannualAssociationofStateandTerritorialDentalDirectors

(ASTDD)StateSynopsisReports(“SynopsisReports”)4.Toassesswhetherastate’s

2

SSPsreacheda“substantial”numberofchildren(approx.10,000eachyear),the

state’smostrecentSynopsisReportsdataonchildrenserved(2011or2012)was

dividedbythenumberofschool‐agedchildrenasreportedbytheUSCensus.*Based

onthesedata,wecontacted13StateOralHealthProgramsformoredetailed

information.Sevenstateofficialsagreedtocompleteapre‐tested34‐question

questionnaire(AppendixA)anda90‐minutetelephoneinterviewwithfollow

up.Fromthesemoredetailedassessments,fivestates(IL,NY,OH,SC,andWI)were

selectedforcasestudies.

Tocapturesealantactivitiesinthe37states(andtheDistrictofColumbia)that

didnotmeetthedefinitionofhaving“substantialandsustainedSSPs,”thoseState

OralHealthProgramDirectorswerequeriedthroughane‐mailed15‐question

survey(AppendixB).Fourlistservs†werealsoqueriedfortheidentitiesoflocal

SSPsthathadeitheroperatedfor10consecutiveyearsorprovidedsealantstoat

least10,000childreninoneprogramyear.Tofurtherbuildunderstandingofhighly

regardedSSPsatthelocallevel,respondentswereaskedtoidentifyonelocal

programthat“mightbethebestinthecountry.”Theseprocessesidentified36local

SSPswhowerethenemailedan8‐questionsurvey(AppendixC),towhich27local

programsin22statesresponded.Theirresponsesinformedthefindingsinthis

report.

Thisreportreflectsthebestavailableinformationasprovidedbykey

informants.However,sealantprogramsareinconstantfluxandreported

informationmaynotcaptureallfactorsthataffectSSPs’reachandsustainability.

Thereportalsobuildsonandcomplementssignificantreportsandresources,

including:a2013reviewbythePewChildren’sDentalCampaignofstates’

* *Penetration was grossly estimated by dividing the number of children the respective SOHPs were able to document as having received sealants via SSPs for the most recent year for which they had complete data (2011‐12 or 2010‐11) by the number of school‐aged children in the state according to the 2010 U.S. Census.  † 1. *University of Pittsburgh. Pitt Dental Public Health Mailing List.  Referenced at: https://list.pitt.edu/mailman/listinfo/dental‐public‐health; 2. Association of State and Territorial Dental Directors (ASTDD) ListServ. Referenced at: http://www.astdd.org/membership‐benefits/; 3. National Network for Oral Health Access (NNOHA) Listserv. Referenced at: http://www.nnoha.org/join/nnoha‐listserv/ ;  4. Community Oral Health Programs E‐mail Discussion List. Referenced at: http://lists.mchgroup.org/listinfo.cgi/cohp‐mchgroup.org.  

3

performanceonfoursealantmeasures;‡earlierrecommendationsmadebythe

collaborativeWorkshoponGuidelinesforSealantUsein1994;5theCommunity

TaskForceonPreventiveServicesin2013;6theAmericanDentalAssociation’s

CouncilonScientificAffairsin2008;7andtheCDC‐sponsoredexpertworkgroupin

2009;8aswellasmaterialsprovidedbySealAmerica©9andtheNationalMaternal

andChildOralHealthResourceCenter.10Itseekstocomplementinformationfrom

ASTDD’s“BestPracticeApproachReportonSchool‐basedDentalSealantPrograms”

(availableatwww.astdd.org/school‐based‐dental‐sealant‐programs‐introduction/)

byprovidingacomprehensiveassessmentofSSPsandhighlightingcharacteristics

thatsupportefficiencyandeffectiveness.

‡ 1. The prevalence of programs in “high‐need schools”; 2. Allowance of sealant placement by hygienists without a prior dentist examination of the child; 3. Compliance with data collection and reporting; and 4. Attainment of national sealant oral health objectives. 

4

FINDINGS

DiversityofModels

Takentogether,studyinformantsidentifiedmorethan640SSPs;most

reportedlydeliversealantsaspartofabroaderschool‐affiliatedcariesprevention

programwhichmayincludedentalscreening,dentalprophylaxis,topicalapplication

offluorides,andoralhealtheducation.InformationonSSPdesignwasprovidedby

39statesandtheDistrictofColumbia.Ofthose,27statesreportthat“allormost”

SSPswerepartofbroadercariespreventionprogramsand13reportthat“atleast

some”SSPswerepartofsuchprograms.

RolesofStateOralHealthPrograms(SOHPs)

Nearlyallofthe40SOHPsrespondingreportinvolvementwithSSPs,though

theyhavevariedrolesinprogramdesign,operation,funding,oversight,and

regulation.Ingeneral,SOHPshavegreaterinputandcloserpartnershipswhenthey

providedirectfundingtolocalSSPs.

Almosthalf(n=23)§ofreportingstatesindicatedthattheirSOHPprovides

fundingtolocalentitiestooperateschoolsealantprograms.Threestates(MA,ND,

NM)reportedthatSOHPsprovidegrantsforSSPsinadditiontooperatingtheirown

SSPs.FourSOHPs(AR,CT,SC,UT)reportedprovidingnodirectfundingforSSPsbut

supporttheseprogramsthroughfacilitation,coordination,regulatoryaction,and/or

reporting.

SOHPsin13statesweredirectlyinvolvedintheoperationofSSPs:five(DC,DE,

NC,OR,TX)byprovidingorcontractingforSSPstaff;five(GA,LA,MS,TN,VA)by

fundingandcollaborativelyoperatinglocalSSPs;andthree(MA,ND,NM)byfunding

localSSPsandalsooperatingtheirownSSPs.

OrganizationsthatManageSSPs

Amongthe664programsdescribedbyourinformants,thetypesof

organizationsthatmanagelocalSSPsvarywidely(Figure1),withone‐in‐three

§AK, AZ, CO, FL, IA, ID, IL, IN, KS, KY, MD, ME, MI, MN, NH, NY, NV, OH, PA, SD, WA, WI, WV 

5

programsdeliveredbylocalhealthdepartments;one‐in‐sixdeliveredbyeither

federallyqualifiedhealthcenters(FQHCs),non‐profitorfor‐profitagencies;and

smallerproportionsbycolleges/universities,schooldistricts,andhospitals.While

SOHPsareoftenengagedwithSSPs,only1%ofprogramsweredelivereddirectlyby

stateoralhealthprograms.

Figure 1 (N=664 programs) 

RegionalPatterns

Differenttypesoforganizationsclusterregionally.

Midwesternstates(IA,IL,OH,WI)arehometo75%ofSSPsmanagedbylocal

orcountyhealthdepartments;Southernstates(FL,GA,NC,TN,VA)arealso

characterizedbyhavingstrongaffiliationswithhealthdepartments.

FQHC‐affiliatedSSPsarestronglyrepresentedintheNortheast(CT,MA,NH,

NY,RI)andafewMidwesternstates(IL,KS,MI,WI)andinWV.NineSOHPs

reportedfiveormoreFQHCsoperatingSSPsintheirstates.

For‐profitSSPprovidersarereportedtooperatein20states;12states

reporthavingmorethanonefor‐profitSSP.Ofthefor‐profitSSPsreported,60%are

foundinthreestates:IL,MA,andWA.For‐profitcompaniesalmostexclusivelyserve

childMedicaidbeneficiariesandsomeextendsomeservicetouninsuredchildren

throughaffiliatedfoundations.

6

FinancingSources

FederalsourcesoffinancingthatcanbeusedtosupportSSPsinclude:

StateOralHealthGrants:competitive5yearcooperativeagreementswith

statesfromtheCentersforDiseaseControlandPreventionDivisionofOral

HealththroughitsState‐BasedOralDiseasePreventionProgram;

FundingtostatesfromtheTitleVMaternalandChildHealthServicesBlock

GrantProgramthatstatesmayallocatetooralhealthprograms;

GrantstostatesundertheHealthResourcesandServicesAdministration

(HRSA)BureauofHealthProfession’sStateOralHealthWorkforceGrants;

and

ReimbursementsfromMedicaidthroughthestate‐administeredEarlyand

PeriodicScreeningDiagnosticandTreatment(EPSDT)pediatricdentalbenefit

andthestate’sChildren’sHealthInsuranceProgram(CHIP)(instatesthat

maintainCHIPplansseparatelyfromMedicaidEPSDT).

Inaddition,statesandlocalesmayprovidedirectfundingforSSPsthrough

generalrevenuesbywayofgrants,contracts,andcooperativeagreements;also,

foundations,professionalassociations,andothernon‐profitsmayprovidecharitable

financing.Industrymayprovidediscountsfordentalmaterialsandsuppliesto

safety‐netprogramsincludingSSPs.Whilenotcommon,SSPsmayalsocollectfees

fromcommercialinsurerswhenchildrenservedhaveprivatedentalcoverage.

Amongfederalprograms,CDC’sState‐BasedOralDiseasePrevention

ProgramprovidesthemostfocusedfundingforSSPs.Twenty‐onestatesreceive

thissupport**to“strengthentheiroralhealthprogramsandimprovetheoralhealth

oftheirresidents.”11Amongtargetedexpendituresare:

supportforastate‐widesealantcoordinator,

** CO, CT, GA, HI, ID, IA, KS, LA, MD, MI, MN, MS, NH, NY, ND, RI, SC, VT, VA, WV, WI. In 2010, Congress authorized the expansion of CDC program funding to all states through The Patient Protection and Affordable Care Act. Authorized expansions will require future Congressional appropriations.

7

 

Twenty‐one states receive CDC support for school‐based sealant programs. This funding covers various needs, including state‐wide sealant coordinators and data collection.  

translatinganddisseminatingthescience

supportingschool‐basedsealantprogramsas

aneffectivepreventiveintervention,

monitoringdataforprogramefficiencyand

reach,

carryingoutBasicScreeningSurveysfor3rd

graders,and

fundingforportablesealantequipment.

TheTitleVMaternalandChildHealthServicesBlockGrantProgramisa

federalpartnershipwithstatesthatsupportsawiderangeofpublichealth,

infrastructure,andclinicalservicestargetingwomenandchildrenwithafocuson

specialneedspopulations.12FundscancomplementMedicaidandCHIPfee‐for‐

servicepaymentsby“providinggap‐fillingservicestoenrollees;assistinginthe

identificationofpotentiallyeligiblebeneficiaries;andcreatinganinfrastructurein

communitiestoensurethatthecapacityexiststosupportthedeliveryofquality

healthcareservicesforwomenandchildren.”13TheMaternalandChildHealth

Bureau(MCHB)alsonotesthat“successfulcoordinationofTitleVwith

Medicaid/CHIPprogramsassistsinmaximizingFederal,Stateandlocalfundsto

meetthehealthcareneedsoflow‐incomewomenandchildren.”14Manystates

utilizeTitleVfundingtosupportSOHPfunctionsincludingthedesign,

implementation,andmonitoringoftheirSSPs.ExamplesincludeIllinois’useofTitle

Vfundstoprovidesealantstohigh‐caries‐riskchildrennoteligiblefor

Medicaid/CHIPandNewYork’ssignificantexpansionofitsSSPwithTitleVsupport

in1995.

TitleV,withabreadthofmaternalandchildhealthinterestsandcollaborations,

alsoprovidesaplatformforSOHPstopromoteoralhealthwithpartnergroupsand

tohighlighttheimportanceoforalhealthanddentalcarewithmaternalandchild

communitiesofinterest.Forexample,WI’s2010MCHBNeedsAssessmenttoIdentify

Prioritiesfor2011‐2015identifiedtheSOHPasa“PrimaryPartner”inreachingthe

8

MCHBNationalPerformanceMeasure(#9)onthe“percentofthird‐gradechildren

whohavereceivedprotectivesealantsonatleastonepermanentmolartooth.”

Acrossstates,SSPscontributevariablytothefulfillmentofthismeasure’sstate‐

specificannualgoal.15Forthelatestyearavailable††,therangeofperformancefor

thismeasurewas13.8%inFloridato73.6%inDelaware,withanaverageacrossall

statesof42.3%.

MCHBintermittentlyreformulatesitssetofrequiredTitleVPerformance

Measuresandisexpectedtoissuethenextsetin2015.Whilethesealantmeasure

hasservedSSPswellinhighlightingtheimportanceofdentalsealantstochildren’s

oralhealthandintrackingprogressinreachingHealthyPeopleoralhealth

objectives,it—likeallsuchmeasures—issubjecttorevisionorelimination.

StateOralHealthWorkforceGrantsadministeredbyHRSAcompetitivelyfund

10statestoimplementoneormoreof13designatedactivitiesthathelpstates

expandtheiroralhealthworkforceindentalhealthprofessionalshortageareas.

Amongallowableactivitiesare“community‐basedpreventionservicessuchas…

dentalsealantprograms”andotheractivitiesthatcansupportSSPs,including

teledentistry,mobiledentalprogramsinunderservedareas,supportofdental

trainees,and“thedevelopmentofaStatedentalofficerpositionortheaugmentation

ofaStatedentalofficetocoordinateoralhealthandaccessissuesintheState.”16

Inearlierfundingcycles,29stateshaveutilizedgrantfundstosupport

community‐basedpreventiveservices‡‡includingOhiowhichusedfundingto

expanditssealantnetwork.

MedicaidandCHIPreimbursementsareacriticalrevenuesourceforSSPs:21

of23localprogramsrespondingtooursurveyreportbillingMedicaid.Although

Medicaidisasustainablefundingsourceforchildren’sdentalcarethatmaybe

utilizedbySSPs,statesvaryconsiderablyinpaymentratesandinadministrative

rules,policies,andpracticesthatimpactSSPs’accesstothissourceoffunding.

†† 2012 reports from all states except FL which reported 2011 data ‡‡ Analysis by Tener Huang and Burton Edelstein reported in a 2014 NOHC abstract  

9

Billing:Aswithallproviders,SSPsthatbillMedicaidareimpactedbyclaims

processingrules,numbersandtimingofsimultaneousclaimsbyprovideror

location,claimsreview

procedures,claimsformatsand

submissionprocesses,and

timelinessofpayment.

Allowableprovidersandservice

locations:Whilemoststatesallow

hygieniststoprovidesealantsin

SSPs,programsareimpactedby

Medicaidinterpretationofstate

licensurepoliciesonlevelsofsupervisionofhygienistsandscopeofpractice,

provisionofuniquebillingcodesforhygienists,anddisallowanceofsealant

billingintheabsenceofadditionaldentalservices,suchasdental

examinationsandradiographs.

Services:StateMedicaidpoliciesoftenproscribetheageofchildreneligible

forsealantbenefitsorregulatetheparticularteeththatcanbesealedaswell

asthefrequencywithwhichpaymentwillbemadeforre‐sealingteeth.

Programtypes:Statepoliciesvaryonthetypesofprogramsthatcanbill

Medicaid,forexampleprohibitingclaimsfrommobiledentalprogram

operatorsorschooldistricts.AsstateMedicaidprogramsshiftintomanaged

carecontractingfordentalservices,SSPsmaybefurtherimpactedasnon‐

networkproviders.

“FreeCareRule”:Federalhealthinsuranceprograms,includingMedicaidand

CHIP,prohibithealthcareprovidersfromchargingmoreforservices

deliveredtopublicbeneficiariesthanarechargedotherpayers,including

commercialinsurersandtheuninsured.SinceSSPsaretypicallydesignedto

deliversealantservicestostudentswithoutcharge(i.e.,“freecare”),anSSP’s

abilitytobillforsealantsdeliveredtoMedicaid‐eligiblechildrenisimpacted

10

 

Medicaid and CHIP reimbursements are a critical revenue source for SSPs. Yet states vary widely in payment rates and in the rules, policies, and practices that impact SSPs’ access to this funding. 

bytheirstate’sinterpretationofthispolicy.Significantly,onOctober8,2013

theU.S.DepartmentofHealthandHumanServicesOfficeofInspector

General(OIG)addresseditsMedicaidenforcementpolicybystatingthatfree

careprovidedtoneedychildrenwhoareuninsuredorunderinsureddoesnot

affectdeterminationofcustomarycharges

andallowablebillableamountsfor

servicesprovidedtoMedicaidbene‐

ficiaries.17Whilewritteninresponsetoa

specificappeal,thisOIGOpinionmayhelp

statesimplementtheMedicaidfreecare

policymoregenerallybyclarifyingthat

federalMedicaidenforcementpolicyis

liberalwithregardstofreecarefor

financiallyvulnerablechildren—allowingbothMedicaidbillingandfreecare

fortargeteduninsuredorunderinsuredchildren.Theopinion,however,is

limitedwithregardtorequirementstobillnon‐governmentalinsurers.

ClearlyneededisauniversalrulingbyMedicaidthataddressesthe

appropriatenessofbillingMedicaid,butnotothers,throughSSPs.

Inadditiontoservice‐specificfeespayablebyMedicaid,thefederal

governmentsupportsstatestoadministerMedicaidthroughan

“AdministrativeMatch”forwhichthefederalgovernmentpaysstatesone

dollarforeverystatedollarcommittedtoprogrammanagement.Illinoishas

utilizedthisAdministrativeMatchforitssealantprogrambyhavingthe

SOHPprovidequalityassuranceservicestoMedicaid.TheSOHPreviews

operationsofallSSPsthatbillMedicaid,conductsannualstructuredsite

visitsoftheseprograms,providesadministrativeservicesrelatedto

providingsealantstoMedicaidbeneficiaries,andprovidesinformationto

Medicaidonevidence‐basedoralhealthservices.

11

FEATURESOF5STATESWITHSUSTAINABLEANDSUBSTANTIALSSPs

Thelessonlearnedfromcomparingandcontrastingfivestatesthatmeetcriteriafor

bothsustainabilityandsubstantialreachisthatthereisno“one‐size‐fits‐all”

approachtoSSPsuccess.Acrossthesestates,variationsexistinSOHProles,funding

sources,Medicaidpolicyonbillingbynon‐dentistproviders,andattendantstate

policiessuchasMedicaidmanagedcarecontracting,requirementsforschool‐entry

dentalexaminations,andpresenceofschool‐basedhealthcenters.

Illinois(SSPsince1986):PaymentstoSSPsarereceivedforthree‐quartersof

treatedchildreneitherfromMedicaid/CHIPorfromstatefundsallocatedto

childrenwhoareeligibleforsubsidizedschoollunchprogramsbutnotenrolledin

Medicaid/CHIP.Thestateallowsgranteesflexibilityinprogramdesignanddelivery

toaddresslocalconditionsandrequiresgranteestoprovidedentalexaminations

consistentwithastatemandatoryschooldentalexaminationlawpassedin2006.

TheSOHPconductsannualsitevisitsofbothgranteeandnon‐granteeSSPs.Sealant

programspredominateinChicagowheretwo‐thirdsofthestate’sSSPsprovide

moresealantstochildrenthananyotherlocalityorstateinthenation.An

12

  

To enhance efficiency, Ohio contracts with a small number of SSPs that each serves multiple schools.

interagencyagreementbetweentheChicagoDepartmentofPublicHealthandthe

ChicagoPublicSchoolsgovernstheprogramwhichisdeliveredbyfor‐profit

vendorsthatpayanadministrativefeetoparticipate.

NewYork(SSPsince1972):Thestate’sSOHPhaslegalauthoritytosetstandards

for,approve,andmonitoralloralhealthservicesprovidedinpublicschools.The

staterequiresalloralhealthprogramsinschoolstobeaffiliatedwithschool‐based

healthcentersthatprovideprimarydentalcareservices.Itprovidesfunding

throughitsTitleVBlockGrant.Asthestatewiththelongest‐runningSSP,NewYork

hasextensiveexperienceinadaptingtochangingdeliveryandfinancingconditions.

RespondentsreportthatNewYorkiscurrentlychallengedbythreetrendsthatexist

tovaryingdegreesinotherstates:(1)Medicaid’sincreasingdependenceon

managedcarethathasrequiredthestatetoseek“carveouts”allowingcontinued

paymentstoSSPsforchildrenreceivingsealantsinschools;(2)theintegrationof

schoolsealantprogramsintodentalpreventionandtreatmentprogramsthatbegan

in2006‐7;and(3)changingconceptsoftherolesoflocalitiesinpublichealth

reflectedindecreasedprovisionofdirectcarecomplementedwithincreased

provisionoforalhealthpromotionandpubliceducation.

Ohio(SSPsince1984):OhioutilizedTitleV

fundingtooperate18of22localhealth

departmentSSPswhichexclusivelyprovide

sealantservices.SSPsbillMedicaidforsealant

placementsbutnotfordentalexamination,thus

allowingtheexaminationtobeperformedandbilledbyproviderswhomayseethe

childlatertoprovideotherdentalservices.Toenhanceefficiency,Ohiocontracts

withasmallnumberofSSPsthateachservesmultipleschools.Ithasuseda2010

HRSAStateOralHealthWorkforcegranttodevelopastrategicplansupportingSSP

expansionsandrefinementsandhasdevelopedawidely‐usedstateSealantProgram

Manual(availableat

http://www.odh.ohio.gov/~/media/ODH/ASSETS/Files/ohs/oral%20health/Dent

al%20Sealant%20Manual%202012.ashx)andDistanceLearningCurriculum

13

(availableathttp://www.ohiodentalclinics.com/distancelearning.html).TheSOHP

collectsandutilizesdatatomanageandreportontheprogram.

SouthCarolina(SSPsince2003):Thestate’sSOHPprovidesnofundingforSSPs

whichrelyinsteadonMedicaidbillingfor96%ofchildrenserved.Thestatehas

regulatoryauthoritytoapprovedentalhygienistsasprovidersinschoolsunderan

arrangementcalled“publichealthsupervision”governedbyamemorandumof

agreement(MOA).TheSOHPmaintainsan“internalsealantmanagementteam”that

providessupportforandevaluation

ofSSPs.SixSSPsoperateinthestate,

fourunderSOHP‐hygienistMOAs,

withoneprovidingsealantstoover

80%ofSouthCarolinachildren

served.TheSOHPcreditssupport

andcollaborationoftheSouth

CarolinaOralHealthCoalitionwith

itssuccessinbuildingschoolsealantprogramcapacity.

Wisconsin(SSPsince1996):Since2001,thestate’sSOHPhaspartneredwiththe

non‐profitChildren’sHealthAllianceofWisconsintoobtainandleveragemultiple

publicandprivatefundingsourcesandsteadilyexpandSSPs’reachtovulnerable

children.Respondentsreportthatstateleveladministrationprovidescentralized

structurewithroomforlocalimplementation,providingsomeflexibilitytotailorthe

programtocommunitycircumstances.Partnersreportcommitmenttorigorous

datacollectionanduseofthedataforprogrammanagementandreporting.State

policiesallowhygieniststopracticeinpublichealthsettings,includingschools,

underadentist’sgeneralsupervisionandtoplacesealantswithoutarequirement

thatadentistfirstexaminethechild.Medicaidcanbebilleddirectlyforboth

sealantsandanoralhealthassessmentprovidedinschools.

14

KEYSTOSUCCESSFORSUSTAINABLE&SUBSTANTIALSSPs

1. Financing:Whilefinancingiscentraltoallprograms’success,thesurveysand

casestudiesrevealthatavarietyoffinancingapproachescansupporteffective

SSPs.Examplesrangefrompublic‐privatefinancingpartnerships,tomarket‐

drivenmodels,toexclusivelyMedicaid‐financed.

SeenascriticallyimportantisthecapacityofSSPstobillMedicaid/CHIPwhen

providingservicestoenrolledchildren.SOHPsmustworkcollaborativelywith

stateMedicaidprogramstofacilitateSSPoperationsbyreducingcited

administrativebarriersandbyaddressingimpedimentscreatedbysomestates’

interpretationsofthefederal“freecare”rule.Featuredstateswerealsonotably

effectiveinsecuringstatesupportfortheirsealantprogramsthroughallocation

offederalTitleVblockgrantfundsandinsecuringcompetitivefundingthrough

CDC‐sponsoredcooperativeagreementstosupportStateOralHealthPrograms

andinHRSA‐sponsoredOralHealthWorkforceGrants.

2. Partnershipsandcollaborations:Inadditiontohavingpartnershipswithstate

Medicaidauthorities,successfulSOHPswereleadersandfacilitatorsthat

15

  

Successful states like Wisconsin used data to create persuasive arguments for state and private financing of SSPs. 

arrangedpartnershipagreementsandformalizedcontractsforqualitycontrol

andadministrativesupportoflocalSSPs.Statesalsoleverageddataasin

Wisconsin,whichcreatedpersuasiveargumentsforstateandprivatefinancing.

FeaturedSOHPsaresubstantiallyinvolvedinsupportingadministrative

structuresandaccountability.

3. Efficiencies:Supportingthecostefficiencyand

reachofSSPs,threeofthefivestatesprofiled

havepracticeactsthatpermitdentalhygienists

topracticeinpublichealthsettingsunder

generalsupervision.Efficientprogramsalso

maintainedeffectiveadministrativestructuresandtrackedaccountability.One

state(WI)refineditsdatacollectionanddataanalysestodemonstrate

efficienciesandprogramcost‐effectiveness,therebyattractingsignificant

fundingfromtheprivatesector.§§

4. Adaptability:Featuredprogramsrecognizeandrespondcreativelytotheever‐

changingpolitical,policy,andadministrativecontextswithinwhichtheydeliver

sealantservices.Amongthesearechangingstatepracticeactsthatgovernthe

availabilityandconditionsunderwhichallieddentalprofessionalscan

participateinSSPsandtheevolutionofMedicaidmanagedcarethroughwhich

contractedvendorsbecomesignificantplayersindeterminingthecomposition

ofprovidernetworks.TheAffordableCareActwilllikelyimpactSSPsby

authorizingexpansionsofschool‐basedhealthcenters,bypeggingdental

benefitsforchildrento“benchmarkdentalplans”thatalmostuniversallyinclude

coveragefordentalsealantstoage16,andbydeterminingthattheonly

preventiveservicesthatmustbeprovidedatnocosttothebeneficiaryarethose

receivinganAorBrecommendationfromtheUnitedStatesPreventiveServices

§§ Wisconsin’s model for collecting and reporting data is being adapted by three states in 2014 through the CDC’s Cooperative Agreement with the Children’s Dental Health Project.  

16

TaskForce(USPSTF).TheUSPSTFdoesnotmakerecommendationsforservices

deliveredbydentalpersonnel.***

ClearlyevidentfromthesefourkeystosuccessisthatSOHPleadershipis

essentialinleveragingopportunitiesandcreativelyrespondingtolocal

circumstancesindesigning,implementing,monitoring,andsustainingSSPs.

Effectiveleadershipinvolves:

workingcloselywithotherstomutuallybuildcapacitybasedonshared

goals;

measurementbasedonrelevantmetrics;

mutuallyreinforcingandcomplementaryactivities;and

ongoingcommunicationthatbuildsstakeholderinvestment.

SubstantialreachandsustainabilityofstateSSPsalsorequiresthatSOHPs

leveragemultiplefundingapproachestomaximizefinancialsupportfortheir

programsfrombothgovernmentalandnon‐governmentalsources.

17

  

The nearly 20‐year‐old guidelines for sealant use in community programs need to be updated. Then these revised guidelines must be promoted by federal, state and local officials who oversee sealant programs. 

TRANSLATINGLESSONSLEARNEDTOPRACTICE

Translatinglessonsgleanedfromthisreportandfromadditionalsourcesinto

greateravailabilityofsealantstohigh‐riskUSchildreninschoolswillrequireactive

collaborationandcommitmenttoSSPsamongmultipleplayersincludingsealant

experts,publichealthleaders,thedentalprofessionalcommunity,schoolofficials,

Medicaidofficials,andstateandfederalpolicymakers.

First,thenearly20‐year‐oldguidelinesfor

sealantuseincommunityprogramsneedtobe

updated.Fromthere,strongandpersistent

promotionofrevisedguidelinesbyfederal,stateand

localauthoritieswithinfluenceoversealant

programswillbeessential.

Suggestedstepsinclude:

1. ConveneanexpertSSPSustainabilityWork

Grouptocollaborativelyreviewavailable

informationandrecommendordevelopnewstrategiesforinclusioninASTDD

BestPracticeApproachesandnewresources,asappropriate,inexisting

authoritativeProgramGuidance(e.g.,throughtheAmericanAssociationof

CommunityDentalPrograms’[AACDP]SealAmericamanual).ThisWorkGroup

maybeginbyconsideringthefollowingneedsthathaveemergedfromSSPs:

businessplanningtemplate(addressingfundingsources,staffing,etc.);

protocolforanalyzingandimprovingsealant‐relatedprogrampolicies;

resourcestoassistinassessingandaddressingbarrierstoparticipation(e.g.,

parentalconsent,cooperationofolderchildrenandmiddleschool

personnel);

systemsforeasilyacquiringpatientidentificationnumbersneededfor

Medicaidreimbursement;

protocolsforcollecting,presentingandusingdatatogainnewresourcesand

maintaincurrentfunding;and

18

samplepartnershipagreements.

2.ConveneanexpertSSPDesignandOperationsWorkGroup,primarilyto

updateprogramplanningguidelinesfromthe1994WorkshoponGuidelinesfor

SealantUsethatwerenotaddressedintheCDC’s2009“Updated

RecommendationsandReviewsofEvidence”andhavenotbeenrevisitedsince.

UsingtheWorksheetforDeterminingtheNeedforCommunitySealantPrograms

andDesigningaDirectServiceCommunitySealantProgram

(http://www.dentalcare.com/media/en‐

US/education/ce128/WorkshopGuidelinesSealantUse.pdf),sections1through6,

thisworkgroupcouldbeginbyconsideringthefollowingitemsthathave

emergedfromthisstudyandfromdiscussionswiththosewhooperateSSPs:

strategiesforidentifyingandreachingappropriatehigh‐riskorvulnerable

populations;

strategiesforprovidingappropriateservicesundertheconditionsofschool‐

based/linkedprograms(e.g.,relyingonevidencetodeterminewhich—if

any—servicesaddvalueforparticularchildrenreceivingsealants,andtooth

selectionguidancethattargetshard‐to‐reachpopulationssuchasmiddle‐

schoolchildrenwith2ndmolardevelopment);

strategiesforconnectingchildrenwithsourcesofdentalcarewhile

maintainingadequatepersonneltimetomaximizetheprimaryprogram

objectiveofsealantplacement;

protocolsforshort‐andlong‐termsealantretentionratechecksandother

clinicalqualityassessments;and

protocolstomonitorprogramoperationsforqualityimprovementpurposes

(e.g.,dataonrateofconsentreturn,numberofchildrenreceivingvarious

levelsofservice).

3. ConveneanexpertSSPFacilitatorsandBarriersWorkGrouptoreviewand

analyzefederalandstatepoliciesthatmayfacilitateoractasbarrierstoSSPs,

withinputfromoralhealth,publichealth,andpublicfinancepolicyexperts.This

19

thirdWorkGroupshouldmakespecificrecommendations,includingmodel

policies,topromoteexpansionofcost‐effectiveandefficientSSPs.

OncetheseWorkGroupshavecompletedtheirreports,thecombinedinfluence

ofpublichealthagenciesatalllevelsandoftheirorganizationalpartnerswillbe

criticalbothfordisseminatingnewguidanceandensuringsuccessinincorporating

theupdatedrecommendationsintopractice.Determinativeorganizationalactors

include:

Federalagencies—withcapacitytodrawoninter‐agencycollaborationand

partnerorganizationsupport—toinfluenceimplementation;

StateOralHealthProgramstoinfluenceand/orimplement;and

Localandstate‐operatedSSPstoinfluenceandimplement.

Federalandstateoralhealthofficialshavesignificantoptionsandresourcesto

exercisesuchleadership.TheAssociationofStateandTerritorialDentalDirectors’

BestPracticeApproachreportondentalsealantsisarichresourcethatisregularly

updated.Findingsofthisreport

pointstatestoavarietyof

financinganddeliveryoptions,

partnershipsandcollaborations,

andefficienciesforsustainable

andsubstantialprograms.

Further,thesurveyinstruments

developedforthisreport(see

AppendicesA,B,C)canbe

readilyadaptedbystatesto

closelyexaminetheirsealant

activities.

TechnicalassistanceisavailablethroughCDCandHRSAresourcesandtheir

grantees.ConsultationwithSOHPDirectorswhohavesuccessfullyprioritizedSSPs

20

intheirstatescanfurtherassistallwhoarecommittedtoimprovingchildren’soral

healthandequitythroughSSPs.

CONCLUSION

ThecostofpreventingtoothdecaybyplacingdentalsealantsthroughSSPsis

muchlessthanthecostoftreatingtoothdecaythatwasnotprevented.By

expandingthereachandeffectivenessofSSPs,stateagenciesandtheirpartnerscan

preventthemostcommoncavitiesinthepermanentteethofschool‐agechildren.

Preventionisapowerfultoolforpotentialcostsavingsandformeasurable

improvementsinthehealthandwellbeingofchildrenwhoareatgreatestriskfor

thesignificantconsequencesofunaddressedtoothdecay.Thelessonshighlightedin

thisreportareofferedtohelpprovidefocusandtoassistinmeetingthosegoals.

21

NOTES 1 The Guide to Community Preventive Services. Preventing Dental Caries: School‐Based Dental Sealant Delivery Programs. Accessed at: http://www.thecommunityguide.org/oral/schoolsealants.html 2 Truman BI, Gooch BF, Sulemana I, et al. Reviews of Evidence on Interventions to Prevent Dental Caries, Oral and Pharyngeal Cancers, and Sports‐Related Craniofacial Injuries. Am J Prev Med 2002;23(1S)21‐54. 3 The Guide to Community Preventive Services. Preventing Dental Caries: School‐Based Dental Sealant Delivery Programs. Accessed at: http://www.thecommunityguide.org/oral/schoolsealants.html 4 U.S. Department of Health & Human Services, Centers for Disease Control and Prevention (CDC). Synopses of State and Territorial Dental Public Health Programs.  Accessed at: http://apps.nccd.cdc.gov/synopses/ 5 Siegal MD, Kumar JV. Workshop on Guidelines for Sealant Use: Preface. Journal of Public Health Dentistry 1995;55 (5 Spec. Iss.) 261‐262. Accessed at: http://www.mchoralhealth.org/seal/PDFs/Step1_WorkshopGuidelinesSealantUse.pdf  6 Task Force on Community Preventive Services.  Recommendations on Selected Interventions to Prevent Dental     Caries, Oral and Pharyngeal Cancers, and Sports‐Related Craniofacial Injuries.  Am J Prev Med 2002;23 (1S) 16‐20. 7 Jean Beauchamp, DDS; Page W. Caufield, DDS, PhD; James J. Crall, DDS, ScD; Kevin Donly, DDS, MS; Robert Feigal, DDS, PhD; Barbara Gooch, DMD, MPH; Amid Ismail, BDS, MPH, MBA, DrPH; William Kohn, DDS; Mark Siegal, DDS, MPH; Richard Simonsen, DDS, MS. Evidence‐based clinical recommendations for the use of pit‐and‐fissure sealantsA report of the American Dental Association Council on Scientific Affairs. JADA 2008;139 (3):257‐267. 8 Gooch BF, Griffin SO, Gray SK, et al. Preventing dental caries through school‐based sealant programs: Updated recommendations and reviews of evidence, Journal of the American Dental Association 2009 Nov;140(11);1356‐1365. 9 Carter NL, with the American Association for Community Dental Programs and the National Maternal and Child Oral Health Resource Center. 2011. Seal America: The Prevention Invention (2nd ed., rev.). Washington, DC: National Maternal and Child Oral Health Resource Center. 10 Bertness J, Holt K, eds. 2010. Dental Sealants: A Resource Guide (3rd ed.). Washington, DC: National Maternal and Child Oral Health Resource Center. 11 http://www.cdc.gov/oralHealth/state_programs/cooperative_agreements/index.htm) 12 http://www.hrsa.gov/about/pdf/mchb.PDF 13 http://www.mchb.hrsa.gov/programs/collaboration/ 14  http://www.mchb.hrsa.gov/programs/collaboration/ 15https://mchdata.hrsa.gov/tvisreports/MeasurementData/NationalMeasures/NationalMeasuresMenu.aspx 16 http://www.hrsa.gov/about/news/pressreleases/131030oralhealth.html 17 Office of the Inspector General Advisory Opinion OIG #13‐13 available at http://oig.hhs.gov/fraud/docs/advisoryopinions/2013/AdvOpn13‐13.pdf