Poor oral health has long plagued Kentuckians, due to a myriad of factors including lax dental hygiene habits, high smoking rates, and perhaps most importantly, a lack of access to dental care in many regions that impacts residents from childhood onward.
Over the past quarter century, a committed group of dentists and public health officials have focused on expanding access to preventive services, especially to children, and data from a recent comprehensive report on the state’s oral health shows encouraging gains in preventive care.
A key component of their outreach initiative has been the introduction of dental sealant programs in several school districts with high-risk populations. Dental sealants, if applied correctly and at the right age, are one of the most effective ways to prevent tooth decay in children. As part of KET’s Inside Oral Health Care initiative, we took a closer look at how sealants work and how they fit within Kentucky’s larger framework of preventive services.
A Simple, Effective Barrier to Tooth Decay
Dr. M. Raynor Mullins, professor emeritus at the University of Kentucky’s College of Dentistry, was instrumental in getting dental sealants added to Kentucky’s Medicaid program as a preventive service in the 1990s and has been involved with numerous oral health outreach initiatives across the state during the past 40 years.
To understand how sealants work, Mullins says, you first have to distinguish between the different areas of the tooth and the most effective treatments available to stop bacteria from forming on these areas.
“A tooth has multiple surfaces …smooth surfaces and pit and fissure surfaces,” he says. “Smooth surfaces are the sides of the teeth, and fluorides are very effective about strengthening them. On the other hand, you have these pits, crannies, and fissures on the tops of the teeth and in certain locations on the sides of the teeth, where they are very susceptible to the infection of tooth decay. Sealants are very effective in preventing pit and fissure decay.”
Each sealant is a clear coating that is applied to the top of molars and attaches to the enamel via molecular bonding. Stacy Trowbridge, PHRDH, dental services director for the Barren River District Health Department, describes the application process, as shown in the video below.
“The process of putting on a sealant, we would actually etch the tooth and kind of rough the surface up a little bit so the actual sealant material sticks to it,” she says. “It’s actually just in a little syringe and it comes out very fine, and it goes on in the pits and grooves of the teeth. It’s very wet until you use a curing light to dry it, and then it’s as hard as it’s going to be. And when you take an explorer to go over [the sealant], it’s just as smooth as can be. So you can tell that nothing can get in those pits and grooves and cause cavities.”
The national Centers for Disease Control and Prevention (CDCP) recommend placing sealants on first and second permanent molars after they appear, which would target children in the 6-7 and 11-13 age ranges. If properly applied, dental sealants can last for up to 10 years, which means that children should need at most six procedures (four initial, and then one re-application to each of their first molars) to last them through early adulthood.
As Mullins notes, sealants are effective in preventing decay in the hard-to-treat parts of the back teeth where fluoride is less effective. Dental professionals recommend using sealants in conjunction with fluoride varnish, which is also a covered preventive benefit in Kentucky’s Medicaid program for children and can be applied by a non-professional to the front and sides of teeth. Unlike sealants, fluoride varnish should be applied three or four times a year.
Sealants’ Importance to Children’s Oral Health
According to Medicaid statistics compiled in “Oral Health in Kentucky,” a February 2016 report from the Center for Health Workforce Studies, State University of New York at Albany, the percentage of Medicaid-eligible children ages 0 to 20 who received a preventive oral health service rose from 14.7 percent in 2000 to 38.1 in 2014. That progress has been a long time in the making.
As far back as the late 1970s, Dr. Mullins says, Kentucky included sealants in some of its public health initiatives, but that early momentum stalled for a time before he and other advocates redoubled their efforts in the mid-1990s. That’s when Mullins, along with Dr. Jim Cecil, then the state’s dental director, lobbied to have sealants added to Kentucky’s Medicaid program. That occurred in the 1998 General Assembly, and current regulations allow up to three sealants per 6 and 12-year molar for eligible children from ages 5-20.
Adding sealants as a Medicaid benefit has helped to fuel Kentucky’s rise in preventive care access from 2000-2014, as cited by the SUNY Albany report. The most recent figure still tops out at only 38 percent receiving preventive services, however, and the report notes that only 43 percent of Kentucky’s Medicaid-eligible children received any dental benefit whatsoever in 2014.
The data on sealant programs in Kentucky is incomplete, according to the most recent Medicaid statistics compiled by the SUNY Albany researchers. Preventive services can include several different procedures, such as fluoride varnishes and cleaning as well as sealants, but Medicaid administrators did not include a question about sealant rates in their annual surveys of state programs until 2010.
Whether applied at a private dentist’s office or through a public health program, Mullins believes that sealants should be included as an essential preventive service for all children in Kentucky.
“For sealants to have maximum effectiveness, you need to place those sealants as soon as you can after the eruption of the first molar tooth,” he says.
Mullins says that one of the main barriers to establishing a statewide full-access oral care program for children remains the lack of pediatric dentists in Kentucky – only 107 in 2014 according to the SUNY Albany report, or 4 percent of the total dentist population. “They’re the ones that really promote prevention,” he says.
Furthermore, Mullins says that many general practice dentists in the commonwealth typically concentrate on treating adults, and that some of the ones who do treat children do not accept Medicaid patients.
School Outreach Models Have Proven Effective
In the mid-1990s, Mullins started the Seal Kentucky program at UK’s College of Dentistry along with colleagues after drawing inspiration from the Seal America initiative that was initially launched by Cincinnati dentist Dr. Larry Hill. The Seal Kentucky program, originally funded through a grant from the Robinson Forest Trust, enlists first-year dental students at UK to set up portable clinics in rural Kentucky communities, with faculty supervision.
The program directs preventive services to populations that need them and also gives dental students their first professional experience in a public service-oriented environment. Mullins believes that Seal Kentucky, which continues to this day, helped to get sealants added to Kentucky’s Medicaid coverage in 1998 and led to the rise of more recent school outreach programs administered by public health departments in Kentucky that provide preventive oral care services to children.
According to the Oral Health Department at the Kentucky Cabinet for Family and Health Services, there are currently 23 local health departments participating in the statewide program, targeting schools where more than 50 percent of students are eligible for free or reduced-cost lunches. The CDCP has made similar recommendations for school-based dental sealant programs part of its national public health platform.
These programs, supervised by an area dentist or dental hygienist, are what Mullins believes should be the basis for an eventual oral care network that spans all counties in the commonwealth. In addition to preventive care, he says “outreach programs provide a mechanism which I refer to as classic case detection, for identifying that child who may have suffered the consequences of disease early, and may have an abscess or an existing infection, and we literally have thousands of those in Kentucky.
“To go find these children, and triage them into care to relieve that infection and try to get some treatment in a timely way is a really important part of outreach, too,” he adds.
Successful school-based outreach programs that feature dental sealants include ones in Northern Kentucky, Clark County, and Madison County. Stacy Trowbridge’s program at the Barren River District Health Department started in 2010 with a grant from the Foundation for a Healthy Kentucky, and in the 2014-15 school year treated around 1,300 students.
Trowbridge believes that their Mighty Molar Dental Program has provided preventive services to many children who otherwise would have not received them, and she hopes to expand the program’s outreach in the years ahead.
“I think some of the kids, if we weren’t coming [to the school] they would have no other option due to lack of concern from parents, parents not knowing what’s going on,” she says. “I think our program helps keep kids in school, they don’t have to go to a dental appointment, and I just – I think that if we weren’t here so many would fall through the cracks.”