EFFECTIVENESS OF SEALANT TREATMENT
OVER FIVE YEARS IN AN INSURED POPULATION
JOSEPH B. DENNISON, D.D.S., M.S.,
LLOYD H. STRAFFON, D.D.S., M.S. and
ROGER C. SMITH, D.D.S.
 |
ABSTRACT
|
|---|
Background. The authors analyzed an insurance claim database to evaluate the use and effectiveness of placing sealants on first and second permanent molars of children in private dental practices.
Methods. A retrospective study was conducted using an insured population with sealant coverage at 70 percent of the usual fee in a preferred provider organization plan that limited reapplication to once every three years. Children were selected who were eligible for sealant benefits from July 1, 1990, to June 30, 1991. Two groups were selected for analysis, based on age, as determined by permanent molar eruption dates. Children who received sealants were compared with those who did not to determine post-sealant restorative outcomes after five years.
Results. During the full year of coverage, sealants were used in only 16.3 percent of first permanent molars and 11.6 percent of second permanent molars. The five-year incidence of an occlusal restoration having been placed was 13.7 percent and 20.8 percent, respectively, on nonsealed first and second molars and 6.5 percent and 10.4 percent, respectively, on sealed first and second molars. From years three to five, sealant placement provided only nominal additional preventive effect.
Conclusions. In the population selected, both the incidence of occlusal caries and the use of sealants were lower than expected for both age groups. However, within these groups, molar occlusal surfaces were only half as likely to have been restored in sealed teeth than in nonsealed teeth after five years.
Clinical Implications. Based on the five-year data from a population with a low incidence of caries, the authors found that 15 sealed first permanent molars or 10 sealed second permanent molars prevented placement of one occlusal restoration. Therefore, sealants are more effective when placed in patients with risk factors for occlusal caries.
Sealants are placed as a preventive measure to cover pits and fissures on the occlusal surfaces of posterior teeth at risk of developing caries. The long-term benefit of using sealants on permanent teeth has been well-documented in studies lasting as long as six to 15 years.1–7 However, in early half-mouth studies (in which teeth on one side of the arch were sealed and contralateral teeth remained unsealed), researchers showed that sealant efficacy is directly related to sealant retention,2,3,8 and replacing a sealant after observing marginal debonding, air bubbles or total sealant loss should be considered an integral part of a preventive program in a dental office.3 The goal of placing a sealant is to prevent caries and the need for a dental restoration. Information is needed to demonstrate that sealant placement leads to a reduced prevalence of restorative dentistry. The population at risk of developing occlusal caries is the target group for sealant therapy, while the population at low risk of developing caries may be overtreated with the use of sealants.9
The question of whether all permanent molars should be sealed or only those at a higher caries risk was raised in 1992 by James Mason, M.D., former head of the U.S. Public Health Service, or USPHS. Specifically, the USPHS Healthy People 2000 goal of placing sealants in 50 percent of all children by the year 2000 seems unrealistic.10 The overzealous application of sealants may not provide additional oral health benefits and is costly. In 1990, the Indian Health Service reported that 74 percent of all 9-year-old American Indian children had sealants in place.10 Among U.S. children and adolescents examined during the first phase of the Third National Health and Nutrition Examination Survey, or NHANES III, study (1988 to 1991), about 19 percent had at least one sealed tooth.11
|
SEALANT EFFECTIVENESS
|
|---|
Straffon and Dennison3 reported that sealants that were reapplied at signs of early failure were 95 percent successful in preventing caries over seven years. Thus, if sealants are a part of a controlled preventive program and receive professional supervision, the outcome is positive. In 1990, Romcke and colleagues4 reported that occlusal sealants were successful in 85 to 96 percent of permanent molars over 10 years if 2 to 4 percent of the sealants that had been placed were routinely repaired each year. It is interesting to note that in both studies, sealants needed more reapplication in the first year than at any other time during the study periods.
In 1995, Heller and colleagues12 reported findings of a five-year retrospective study of first permanent molars involving a first-grade population in a community with fluoridated water. They found that in sound tooth surfaces that did not receive a sealant (that is, those with no visible defects or discoloration of the enamel surface and in which the explorer did not catch on probing), 12.5 percent became carious within the next five years. In comparison, 8 percent of the sound teeth that did receive a sealant had restorations placed during the same five-year period. This indicates a protective effect of only 4.5 percent when sealants were placed on sound teeth. By contrast, Heller and colleagues12 found that teeth with incipient pit-and-fissure caries (that is, dark stains, chalky appearance or a slight explorer catch) that received a sealant had a 41 percent lower incidence of caries during the five-year study period.
|
IMPACT OF SEALANTS ON RESTORATIVE TREATMENT
|
|---|
In 1997, Eklund and colleagues13 reported data from a 15-year retrospective study in which they found a substantial decrease in the number of restorations placed in an insured population of children up to age 18 years as well as in adults. In 2000, Brown and colleagues14 reported that among children between the ages of 6 and 18 years, the number of decayed, missing and filled permanent teeth decreased from 4.44 in 1971–1974 to 1.90 in 1988–1994, as measured by the NHANES III study.
For sealants to be of value, they must reduce the need for restorations. With the decreased incidence of occlusal caries in recent years, the possibility of overtreatment as well as the increased costs become concerns that need to be addressed. If the incidence of occlusal caries continues to decline, then the economic factor in regard to sealant use will become of greater importance in analyzing treatment benefit.15,16
Kuthy and colleagues17 evaluated a large database of patients with insurance claims for sealant placement. They followed up the population for three years to study the incidence of restoration placement. For comparison, a similar group of children who did not have sealant benefits was used as the control group. At 30 months, the investigators found essentially no difference between the two groups in the probability of a first molar remaining unrestored (approximately 73 percent survival rate).
In 1995, Ismail and Gagnon18 reported findings of a two-year longitudinal study on the effectiveness of fissure sealants applied to first permanent molars in children aged 6 to 9 years in private dental practices in Montreal, Quebec. This community did not have fluoridated water. Most sealants were applied under a provincial dental insurance program. At the follow-up examinations two years later, 10.9 percent of the nonsealed molar surfaces that had been diagnosed as sound, with unstained fissures, at the beginning of the study were restored. However, the incidence of restoration in previously sealed molar surfaces was 2.7 percent, a reduction of 75 percent through the application of sealants. In noncavitated surfaces with deeply stained fissures, the incidence of restoration was 34.6 percent. Thus, the 2.7 percent incidence of restoration in the previously sealed molars represents a reduction of 92 percent when these teeth at higher risk were evaluated.
The purpose of this retrospective study was to evaluate the clinical outcomes after sealants were placed in children covered by private dental insurance in Michigan. We also assessed the use of sealants by private dentists.
|
MATERIALS AND METHODS
|
|---|
During the period from July 1991 to June 1997, we studied one large group that had dental insurance coverage, including sealants, through Delta Dental Plan of Michigan. The beneficiaries represented a population with varied jobs, education and socioeconomic backgrounds. Inclusion criteria for this study included the following:
- – the beneficiaries’ children had to be eligible for all benefits during the entire five-year period;
- – the beneficiaries must have submitted a claim from a participating dentist for a dental prophylaxis for the child between July 1, 1991, and June 30, 1992;
- – the beneficiaries must have submitted at least one claim for dental care for the child between July 1, 1993, and June 30, 1994.
The prophylaxis provided proof of an active nonemergency patient status, with at least one recall examination during the year after which the child became eligible for benefits.
Two age groups.
The children were selected from one of two age groups for evaluation of treatment to the occlusal surface of the permanent molars and longitudinal follow-up. They were identified by their birth date and their availability for sealant placement during a one-year window from July 1, 1991, to June 30, 1992. Group 1 included children aged 5
through 7 years (until the eighth birthday); we evaluated the clinical outcome of sealants placed on the occlusal surface of their first permanent molars. Group 2 included children aged 11 through 13 years (until the 14th birthday); we evaluated the clinical outcomes of sealants placed on the occlusal surfaces of their second permanent molars.
Eligibility.
The claims data for the occlusal surfaces were collected by Delta Dental Plan of Michigan for the same sample at the end of the third, fourth and fifth years after the date at which the children became eligible for treatment (July 1, 1991). There were 235,655 children eligible for benefits under this contract, with 10,159 children in the age range selected for evaluation of first permanent molars (group 1). From this group, 795 children had no dental claims, 3,294 had a claim but received no prophylaxis and 867 received a prophylaxis but submitted no further claims, leaving 5,203 children as the sample eligible for evaluation of sealant use and efficacy in first permanent molars.
For evaluation of second permanent molars, 12,241 children were in the specified age range (group 2). From this group, 983 children had no dental claims, 4,099 had a claim but received no prophylaxis and 1,344 received a prophylaxis but submitted no further claims, leaving 5,815 children as the sample qualifying for evaluation of second permanent molars.
Fluoridation.
Most of the children in this population lived in communities that had fluoridated water. As of 1992, more than 65 percent of the population in Michigan was receiving fluoridated water according to the U.S. Department of Health and Human Services.19 Because these families were geographically stable during the study period, we assumed that most of these children drank fluoridated community water from birth.
Dental insurance plan.
Fee-for-service payment was the insurance coverage received by beneficiaries. Sealant coverage was provided at 70 percent of the usual fee in a preferred provider organization, or PPO, practice plan, and at 50 percent for patients receiving care at a non-PPO practice. Reapplication of sealant was a covered benefit only after three years from the original sealant placement. Participating dentists were paid on the basis of their usual and customary fee, up to that of the 90th percentile of participating dentists in Michigan. Throughout this period, the level of coverage did not change and treatment was provided by both general practitioners and pediatric dentists.
|
RESULTS
|
|---|
Utilization.
The number of children who were in the appropriate age range for first permanent molars was 10,159 (Table 1
). Of these children, only 850 had claims that were submitted for sealants, for an 8.4 percent overall utilization of the sealant benefit. Of the 5,203 children in group 1 who were identified as having received prophylaxis and some form of additional treatment during the recall periods, 850 had sealant claims, which represents a 16.3 percent use rate for the sealant benefit. In regard to general use of the insurance benefits in this group, only 5,203 children from the original pool of 10,159 repeatedly used any of the covered services during the first two study years (51.2 percent utilization rate). Previous claims history documented the geographic stability of this population. Therefore, the potential for use of sealants should approach 100 percent if all participating dentists used the procedure routinely.
The number of children eligible for sealant placement on second permanent molars (group 2) was 12,241 (Table 1
). Of these, only 677 submitted claims for sealants (5.5 percent utilization). For the 5,815 children who received prophylaxis and some form of additional treatment, the 677 sealant claims represent an 11.6 percent benefit use rate. Overall, repeated use of dental benefits by the eligible sample was 47.5 percent in this older age group. Although more children were eligible for care, fewer received repeated treatment and even fewer received sealants than did those in group 1.
Number of children.
Of the 5,203 children who were eligible for sealants on their first permanent molars in the treatment year, 4,353 did not have a sealant placed. After five years, 1,744 (40.1 percent) of these 4,353 children had received at least one occlusal restoration (Figure 1). Of the 5,138 children in group 2 (second molars) who were eligible for sealants but did not have a sealant placed, 3,094 (60.2 percent) had received at least one occlusal restoration during the five-year study period (Figure 1).
View larger version (37K):
[in this window]
[in a new window]
|
Figure 1. Incidence of one or more restorations having been placed in children who did not receive dental sealant.
| |
Number of teeth.
When teeth were used as the unit of study rather than children, 18,052 first permanent molars and 21,830 second permanent molars were eligible for—but did not receive—sealant treatment during the inclusion year (July 1991 to June 1992) (Table 2). The incidence of occlusal restorations being placed on these nonsealed first permanent molars from three years after the study began (9.5 percent) to five years (13.7 percent) increased by approximately 2 percent each year. The incidence of occlusal restorations being placed on the nonsealed second permanent molars from three years (14.9 percent) to five years (20.8 percent) increased by about 3 percent per year. The rate of restoration placement was significantly greater for second molars than that for first molars: 5.4 percent greater after year three, 6.4 percent greater after year four and 7.1 percent greater after year five. Although the incidence of restoration placement is much lower when we consider teeth rather than children (in both age groups), the ratio (cumulative percentage in Table 2) of restored second molars to restored first molars is similar: 1.57:1 after year three and 1.52:1 after year five.
Restorations in group 1.
Of the 20,812 first molars in group 1, 2,760 (13.3 percent) received an occlusal sealant (Table 3). By the end of the third year, 90 (3.3 percent) of these teeth had received an occlusal restoration; by year four, 141 teeth (5.1 percent) had received an occlusal restoration; and by year five, 199 teeth (7.2 percent) had been restored with an occlusal restoration.
Restorations in group 2.
Of the 23,260 second molars in group 2, 1,430 (6.1 percent) had received an occlusal sealant. By the end of the third year, 88 (6.2 percent) of these teeth had received an occlusal restoration; by year four, 114 teeth (8.0 percent) had received an occlusal restoration; and by year five, 149 teeth (10.4 percent) had received an occlusal restoration. For this group of sealed teeth, the ratio of restored second molars to restored first molars showed wider variation, but also decreased from 1.88:1 at three years to 1.57:1 at four years and 1.44:1 after five years. Actual rates of restoration were higher for second molars than those for first molars by 2.9 percent at three and four years and 3.2 percent at five years. This represents parallel rates for both teeth (6.2 to 6.5 percent for first molars), but at a higher level for second molars (8.7 to 10.4 percent) (Figures 2 and 3).
View larger version (48K):
[in this window]
[in a new window]
|
Figure 2. Incidence of restoration placement on first permanent molars with and without sealants. Note the relatively similar sealant treatment effect at all three years.
| |
View larger version (52K):
[in this window]
[in a new window]
|
Figure 3. Incidence of restoration placement on second permanent molars with and without sealants. Note the relatively similar sealant treatment effect at all three years.
| |
Protective effect of sealants.
Figure 2 illustrates the advantage of placing sealants on the occlusal surfaces of first permanent molars over leaving the occlusal surfaces nonsealed. Similarly, Figure 3 shows the value of placing sealants on the occlusal surfaces of permanent second molars. The protective effect was more dramatic for second molars than for first molars, but the results show little change in protective effect between the third and fifth years for either first- or second-molar groups.
During this five-year study, the vast majority of first and second permanent molars did not receive an occlusal sealant, even when most of payment was provided by the insurance plan. By the end of five years, 2,465 (13.7 percent) of the 18,052 nonsealed first permanent molars had received an occlusal restoration. Of the 2,760 first molars that received an occlusal sealant, only 199 (7.2 percent) had received an occlusal restoration within five years (Tables 2 and 3). This difference of 6.5 percent (that is, 13.7 percent minus 7.2 percent) is the efficacy of treatment or protection provided to a first permanent molar by a sealant for five years (Figure 2).
During the same five-year period, 4,535 (20.8 percent) of the 21,830 nonsealed second molars had received an occlusal restoration. Of the 1,430 second molars on which an occlusal sealant had been placed, 149 (10.4 percent) had received an occlusal restoration within five years (Tables 2 and 3). This difference of 10.4 percent (that is, 20.8 percent minus 10.4 percent) is the protection provided to a second molar by a sealant for five years (Figure 3).
Table 4 shows the relative risk of restoration placement after sealant placement in each group. It is calculated as a ratio of the incidence of restorations in the sealed group to the incidence of restorations in the nonsealed control group at each interval. On a yearly basis, the protective effect of treatment decreased with time. The relative risk of restoration of first molars during the fifth year after application is 0.96, an equivalent risk regardless of whether sealant was placed or not. For second molars, there is still a protective effect during the fifth year (0.79), but the trend is approaching 1.0. In general, the risk of restoration placement was about 50 percent less in subjects in the sealant groups than in subjects in the nonsealant groups; however, the absolute incidence rates of restoration placement were quite small in all groups (less than 20 percent overall).
|
DISCUSSION
|
|---|
This long-term retrospective study based on dental insurance claims data examined the outcomes of sealant treatment regimens on the occlusal surfaces of permanent first and second molar teeth in childen living in a community with the halo effect of fluoridated water. In 1993, Li and colleagues19 reported that the increased availability of fluoride in various forms—including water fluoridation, fluoride in processed foods, fluoride rinses and dentifrice, and professionally applied topical fluorides—has made a significant contribution to the decline of caries. This could provide a halo effect, lowering caries prevalence in the study population and masking the potential effect of sealants.
Our original intent was to evaluate posttreatment data using only the longest available posttreatment period (three years). However, developing the software program to access the full database took much longer than expected and data also became available for the fourth and fifth years.
The use of sealants in the original two age groups of children (10,159 and 12,241 children, respectively, in groups 1 and 2) was extremely low, even though placement was a covered insurance benefit. At this utilization rate (8.4 percent for first molars and 5.5 percent for second molars) (Table 1), sealants had an almost insignificant effect on population-based treatment or health care costs. We found it surprising that even though sealants were a covered benefit, few dentists were applying them. However, it is not surprising that the incidence of occlusal restorations was also low in these age groups.
The USPHS oral health goals outlined in the Healthy People 2000 document20 specify that at least 50 percent of all schoolchildren should have sealants in place to protect the occlusal surfaces from potential caries. The data presented here indicate how far we are from reaching this goal, even when sealants are a covered insurance benefit. Within the most restrictive criteria for selection into this study—that is, children receiving repeated dental care annually—only 5,203 (51.2 percent) of the 10,159 eligible children in group 1 qualified. Of the 12,241 eligible children in group 2, only 5,815 (47.5 percent) received repeated dental services. The repeated use of dental benefits in this group of children was about 20 percent lower than that reported by Eklund and colleagues.13
Usually, epidemiologic data are analyzed on a per-tooth basis, assuming that every tooth is a relatively independent unit that has a specific life cycle and end point. However, if a long-term goal in the United States is to have children free of caries, the assumption that one permanent molar restoration is a failure that could have been prevented provides meaning to the data in Figure 1. Without sealant treatment, 40.1 percent of children in group 1 had at least one first molar restored after five years, and 60.2 percent of children in group 2 had at least one second molar restored. This 20 percent higher incidence of caries in second molars highlights the importance of tooth location, occlusal morphology, patient age and changing dietary factors in determining caries risk. It is obviously more difficult to achieve the goal of having all children remain free of caries than it is to achieve a single caries-free tooth.
The relevance of this study is in the comparison of five-year restoration history data between molars receiving sealant treatment (Table 3) and those not receiving it (Table 2), for whatever reason. On a single-tooth basis, the incidence of restoration in nonsealed permanent molars within five years of eruption is relatively low: 13.7 percent for first molars and 20.8 percent for second molars (Table 2). Given this level of disease in the insured population selected for study, the incidence of restoration after sealant treatment was reduced by approximately one-half in each group: to 7.2 percent for first molars and 10.4 percent for second molars (Table 3).
In the group of children with 2,760 sealed first molars, 378 (13.7 percent) of these teeth would have been expected to need restorations after five years if they had not been sealed. Since 199 restorations were actually placed, this means that 179 were prevented. Thus 2,760 sealed molars eliminated the need for 179 restorations, or 6.5 percent of sealants continued to be effective after five years. Another way of looking at this is that 15 sealants prevented one restoration from being placed during the five-year study period. In light of the cost/benefit ratio evident in this data analysis, the potential success of using sealants routinely in this type of population is doubtful, and we do not recommend it.
Similarly, in the group of children with 1,430 sealed second molars, 297 (20.8 percent) of these teeth would have been expected to need restorations within five years if they had not been sealed. Because 149 restorations were actually placed, this means that 148 restorations were prevented, or 10.4 percent of the sealants had a preventive effect at five years. In other words, placement of 10 sealants eliminated the need for one restoration.
The findings of this study agree with those of Heller and colleagues.12 They reported a restoration rate for nonsealed sound first permanent molars of 12.5 percent over five years compared with 13.7 percent for teeth in our study. For sealed first permanent molars, the restoration rate reported by Heller and colleagues12 was 8.1 percent compared with 7.2 percent for teeth in our study group. In both studies, the effective risk reduction for teeth receiving sealant was approximately 50 percent over five years.
The results of this study show that the risk of occlusal pit-and-fissure caries on permanent molars can be reduced by 50 percent after five years (Table 4). Thus, the real challenge in developing effective sealant programs is to more accurately identify patients or teeth at higher risk of developing caries and to concentrate treatment resources on this population. Given the retrospective nature of this study, there is no evidence that sealants were placed on subjects who were at risk or that the control group was not assigned randomly. Our data strongly support the view that, for sealants to be effective, they must be allocated to children who are at high risk of developing caries and not be applied routinely throughout a dental practice population. We believe that the protective effect of sealants would be better demonstrated in a prospective controlled clinical trial composed of children at high risk of developing caries who receive sealant applications in a randomized fashion.
|
CONCLUSIONS
|
|---|
Within the limits of a retrospective study and the characteristics of an insured population in private practice, we can make the following conclusions. The use of sealants in private dental practices with 50 to 70 percent insurance coverage was surprisingly low (16.3 percent for first permanent molars and 11.6 percent for second molars) during a one-year period for active patients visiting participating private dental practices. The incidence of an occlusal restoration being placed on nonsealed first and second permanent molars was 13.7 percent and 20.8 percent, respectively, during this five-year study period. During this period, the incidence of an occlusal restoration being placed on sealed first and second permanent molars was 7.2 percent and 10.4 percent, respectively. Fifteen sealed first molars or 10 sealed second molars resulted in the prevention of one occlusal restoration.
The rate of restoration placement was relatively constant and similar for both first- and second-molar groups from post-treatment years three through five, indicating only a nominal treatment effect for sealants after the third year. Although the overall incidence of carious disease was very low in this insured population, the cumulative risk of restoration placement on first and second permanent molars was reduced to 34 and 41 percent, respectively, at three years and 53 and 50 percent, respectively, at five years as a result of placing a pit-and-fissure sealant.
|
FOOTNOTES
|
|---|
This study was funded in part through a research grant from Delta Dental Fund of Michigan.
Dr. Dennison is a professor, Department of Cariology, Restorative Sciences and Endodontics, School of Dentistry, the University of Michigan, 1011 N. University, Ann Arbor, Mich. 48109. Address reprint requests to Dr. Dennison.
Dr. Straffon is a professor, Department of Orthodontics and Pediatric Dentistry, School of Dentistry, the University of Michigan, Ann Arbor.
Dr. Smith is a senior dental consultant, Delta Dental Plan of Michigan, Lansing, Mich.
|
REFERENCES
|
|---|
- Houpt M, Shey Z. The effectiveness of a fissure sealant after six years. Pediatr Dent 1983;5:104–6.[Medline]
- Mertz-Fairhurst EJ, Fairhurst CW, Williams JE, Della-Giustina VE, Brooks JD. A comparative clinical study of two pit and fissure sealants: seven-year results in Augusta, Georgia. JADA 1984;109:252–5.
- Straffon LH, Dennison JB. Clinical evaluation comparing sealant and amalgam after seven years: final report. JADA 1988;117: 751–5.
- Romcke RG, Lewis DW, Maze BR, Vickerson RA. Retention and maintenance of tissue sealants over 10 years. J Can Dent Assoc 1990;56:235–7.
- Simonsen RJ. Retention and effectiveness of dental sealants after 15 years. JADA 1991;122:34–42.
- Velkalahti MM, Solavaara L, Rytomaa I. An eight-year follow-up on the occlusal surfaces of first permanent molars. J Dent Res 1991;70:1064–7.[Abstract/Free Full Text]
- Walker J, Floyd K, Jakobsen J. The effectiveness of sealants in pediatric patients. J Dent Child 1996;63:268–70.
- Horowitz HS, Heifetz SB, Poulsen S. Retention and effectiveness of a single application of an adhesive sealant in preventing occlusal caries: final report after five years of a study in Kalispell, Montana. JADA 1977;95:1133–9.
- Swango PA, Brunelle JA. Age- and surface-specific caries attack rates from the National Dental Caries Prevalence Survey (abstract 909). J Dent Res 1983;62(spec. issue):270.
- Palmer C. How many will have sealants in 2000? ADA News 1992; March 23:1, 4.
- Brown LJ, Kaste LM, Selwitz RH, Furman LJ. Dental caries and sealant usage in U.S. children, 1988–1991: selected findings from the Third National Health and Nutrition Examination Survey. JADA 1996;127:335–43.
- Heller K, Reed SG, Bruner FW, Eklund SA, Burt BA. Longitudinal evaluation of sealing molars with and without incipient dental caries in a public health program. J Public Health Dent 1995;55:148–53.[Medline]
- Eklund SA, Pittman JL, Smith RC. Trends in dental care among insured Americans: 1980 to 1995. JADA 1997;128:171–8.
- Brown LJ, Wall TP, Lazar V. Trends in total caries experience: permanent and primary teeth. JADA 2000;131:223–31.
- Eklund SA, Ismail AI. Time of development of occlusal and proximal lesions: implications for fissure sealants. J Public Health Dent 1986;46:114–21.[Medline]
- Eklund SA. Factors affecting the cost of fissure sealants: a dental insurer perspective. J Public Health Dent 1986;46:133–40.[Medline]
- Kuthy RA, Branch LG, Clive JM. First permanent molar restoration differences between those with or without dental sealants. J Dent Educ 1990;54:653–60.[Medline]
- Ismail AI, Gagnon P. A longitudinal evaluation of fissure sealants applied in dental practices. J Dent Res 1995;74:1583–90.[Abstract/Free Full Text]
- Li S, Kingman A, Forthofer R, Swango P. Comparison of tooth surface–specific dental caries attack patterns in U.S. schoolchildren from two national surveys. J Dent Res 1993;72:1398–405.[Abstract/Free Full Text]
- U.S. Department of Health and Human Services, U.S. Public Health Service. Healthy People 2000, national health promotion and disease prevention objectives. Section 13: oral health. DHHS publication 91-50212:357.
TOP
ABSTRACT
SEALANT EFFECTIVENESS
