“Miles of Smiles” draws some frowns

Dental pros dispute school dental sealants program with County officials

Most of us brush our teeth every day, but some of our kids might not, possibly due to false impressions left by dental sealants they are given at school. That thought makes some local dental professionals question not only the durability of the sealants, but also whether they should be administered in schools.

The debate on sealants continued Monday evening, as Mono County Oral Health Task Force Chair Hillary Bayliss hosted an educational discussion, “The Continuum of Oral Health.” The meeting, attended by local dentists and dental professionals, included presentations on the schools sealant program by Drs. Nancy Reifel and Vladimir Spolsky, professors at the UCLA School of Dentistry.

Dental sealants are a treatment consisting of applying a plastic-type material to teeth to prevent dental caries, more commonly known as cavities. School sealant programs are almost as controversial as fluoridating water, which has also met with resistance from opponents who claim that ingesting fluoride is overrated, and the health risks and personal rights infringements are underreported. Supporters, however, argue that in the past 30 years, decay on the smooth surfaces of teeth has declined, in part because of widespread fluoridation in public water supplies.

The “Miles of Smiles” sealant program is a nationwide, state-by-state effort implemented by counties and school districts aimed at providing dental sealants to children unlikely to receive them otherwise at no cost to parents or schools, bolstering oral healthcare, particularly in lower income students.

According to a November 2009 article in the Journal of the American Dental Association (JADA), data shows that children ages 6 through 11, from families living below the federal poverty threshold ($21,800) are twice as likely to have developed caries in their permanent teeth, particularly molars, than their counterparts from families earning twice the federal poverty threshold.

According to background on the program from the University of Texas Health Science Center/San Antonio, children participating in the program receive limited oral examinations to identify dental needs. If parents sign a release form, students receive dental sealants. If an oral health problem is identified (e.g. a cavity), the parent will be asked to schedule an appointment with a local dentist, though generally government entities refrain from endorsing any particular dental provider. The use of dental sealants in school-based programs is backed by the Centers for Disease Control (CDC).

In Mono County, Bayliss said the program includes educational assemblies, evaluations, the sealants and additional fluoride treatments, if opted for by parents. The program locally involves the school districts, the UCLA School of Dentistry and the County’s Oral Health Taskforce, which handles the administrative aspects. UCLA dental students and professors volunteer their spring break to make this program happen. They also provide the dental supplies.

Bayliss said that ideally local dentists and hygienists would run Miles of Smiles; however, so far no Mammoth dental practices have expressed interest. After the weeklong event, the Oral Health Taskforce does follow up on the children who had higher risk findings and works with families, as needed.

Because teeth have numerous pits and fissures on their biting surfaces, certain areas are often difficult to clean, even with proper brushing. Sealants painted over pits and fissures in the chewing surfaces of back teeth block food from being trapped and any carbohydrate-like sugars being changed to acid by normally found plaque bacteria, and halts demineralization, which is at the core of the caries process.

Breaking the seal

Research into dental sealants began in the 1960s, and by the early 1970s the Food and Drug Administration approved the first generation of sealants. Fluoride use has always been advocated as part of a sealant treatment therapy, and historical research shows that it’s actually possible to remineralize or repair smaller caries even down to the dentin layer below the enamel. Some in the dental and healthcare communities view sealants as protective additions to an arsenal that also includes normal saliva, fluoride rinses and toothpastes, and antibacterial treatments, such as iodine solutions.

According to data from studies, as presented by Dr. Spolsky, “one-shot” applications on permanent molars reduced caries by 78% in one year, and 59% over four or more years. Spolsky said he’s gone through lots of studies, documentation and reviews of sealants, adding, “There’s lots of crappy stuff published in literature” about sealants, much of which he takes issue with.

Sealants, he noted, also reduced non-cavitated legions 71%. Further, he went on to illustrate, the percentage of a tooth’s surface becoming carious drops considerably with sealant. Otherwise sound teeth have a 12% chance of developing cavities without sealing, whereas a sealed tooth has only an 8% chance. Teeth with potential problems fare even better, on a percentage basis, with non-sealed teeth 52% likely to form cavities, as opposed to only 12% for sealed teeth.

Spolsky’s findings showed there’s no significant increase in bacteria under sealants, and in fact they were shown to lower bacteria 100 fold. “We recommend sealing non-cavitated legions,” Dr. Reifel added. “It’s not harmful to the tooth, and even if the decay is progressive, you have a much better chance for treatment at a later date.” In short, she said, even if all or part of the sealant is lost, the tooth is no worse off than if it were not sealed.

“[Sealant] is the best way to deal with occlusal areas, as opposed to smooth surfaces; it doesn’t matter how it’s cleaned,” Spolsky said. They can even be cleaned with a dry toothbrush and have essentially the same result as using toothpaste.

Seal of disapproval

Not everyone agrees, however, that sealants are entirely effective. The Journal of Dental Research, for example, while stating there’s “strong evidence that sealants are effective in both clinical and school settings,” said the evidence of effectiveness is limited. According to the Journal, sealant prevalence among lower-income children is about 30%, well below the Healthy People 2010 objective of at least 50%.

One thing that bothered some dental professionals in the room, such as Dr. Craig Schrager and his wife, Tina, who is a Dental Hygienist in his practice, is why some sealants fail early on and have to be replaced. Dr. Schrager said that was a concern when sealants were being developed more than 20 years ago.

In the June 2011 edition of his monthly “Clinicians Report,” Dr. Gordon Christensen said premature failure is commonly observed, but added that when properly placed they can provide years of preventive service. Christensen’s report is compiled largely from independent field reports sent in by general practice dentists, based on their observations in the clinical workplace.

Sealant longevity, Christensen pointed out, has been shown to be relatively short and unpredictable. At about five years, research shows that 50% of sealants have been lost. Most sealants fail, he writes, due to poor techniques, such as inadequate cleaning, failure to remove existing caries, and inadequate physical properties of the materials under load and stress.

His wife, Dr. Rella Christensen, Chair of the Clinical Research Associates Foundation Board of Directors, suggested that sealants aren’t as simple and foolproof as many parents are led to believe. “I submit that sealant placement as it is practiced in the U.S. today is inherently flawed, due to the desire for sealants to be a fast, easy, inexpensive procedure,” she stated.

Schrager thinks the problem could even be worse than the Christensens indicate.

“When the sealants are gone three weeks after the program, there’s something wrong,” he said. Reifel said she thinks the problem of application versus retention comes down to moisture content on the teeth. She said glass ionomer sealants (as opposed to the more common resin-based forms) are used when there is more moisture present, but do have a lower retention rate, needing to be checked and likely replaced about a year out. “They’re effective just the same, but many school programs have shied away from using glass ionomers on teeth,” she said.

“Generally, we see a 90% effective rate, but we wouldn’t know if a sealant was redone, unless the sealant material is a different color,” Reifel said in a Sheet interview last year. In the dental community, there’s a group of dentists [out there] who have a very hard time with the idea that we don’t necessarily have to see what’s underneath [the sealant]. Bacteria trapped underneath a sealant can be essentially killed off. To do the procedure, you need good isolation, keep the tooth absolutely dry. We use a number of different devices designed to keep the tooth dry, devices that local offices often don’t have.”

On a socio-economic level, the Schragers assert that low-income access to dental care is available locally via Mammoth Hospital’s dental clinic, which provides coverage under several different government-sponsored programs. The doctor is, however, concerned about the future of that access. “Every kid should be able to have dental care,” Dr. Schrager said. “We don’t need a school sealant program, we need an outreach program at soccer sign ups for example, everything, to get them into Denti-Cal (the dental branch of Medi-Cal). Once the state’s Healthy Family program switches to Medicaid, that could knock a lot of kids out of access to dental care.”

Reifel added that the school sealant program is designed to reduce time away from school for students’ dentist appointments. Schrager, however, also criticized the program for what he thinks is excessive school time consumed and the program’s lack of proper coordination.

Assumptions & misperceptions

In addition, the Schragers also voiced concerns that too many students make the assumption that their “dentist” is “at school.” Given Mammoth’s heavily transient-skewed population, many kids might not be getting the right kind of education about how proper dental care works. “There’s a misperception that, ‘My teeth are sealed; I don’t have to go to the dentist,’” the Schragers posited. “We’re being bombarded with this on a daily basis … no X-rays are taken and kids could have cavities between their teeth.”

Former First 5 Mono County Director Kathy Peterson said Miles of Smiles is “not a substitute for an individual dental care program for each student,” but rather “a way to help with such a program.”

Dr. Reifel recommended removing private practice patients, and asking their parents not to sign the consent form, which would allow the program to spend its time and money on more indigent patients without access.

One professional who’s a fan of the program is recently departed Mammoth dentist Dr. Byron Sansom. “The school-based sealant program is a good thing, and I stand beside the CDC, National Institute of Health and the [state] legislature,” he said in a previous interview.

Sansom stands by research that says sealants can prevent tooth decay 30 to 60%. The controversy, he said, comes from the old paradigm that you can’t cover over decay, but you can cover a non-cavitated lesion. Old school dentists, he thinks, have a hard time believing in non-invasive procedures. “The problem is that non-invasive dentistry doesn’t pay, and that’s threatening to a graduate out of dental school who is $500,000 in debt,” Sansom said.

He also noted that the sealant procedure comes with paperwork sent home that advises following up and seeing a proper dentist. The idea, he assessed, is it does the most good for the greatest number. Sansom added he also wasn’t concerned about who’s performing the sealant procedure. He believes a trained student or assistant is qualified.

Was his office united behind those opinions? “Probably not, because it’s threatening,” he said, “but we need to help more people. Jealousy. Let’s get past that.”

If it’s a tug of war between of public health versus private practice, don’t look for any change in direction from Mono County, which apparently plans to remain all smiles. “This isn’t only about Mammoth Lakes, but also about Mono County,” according to County Public Health Director Lynda Salcido. “We’re going to continue to work with UCLA to bring school sealant programs to Mono County.”