Department of Health and Children Seminar

April 2005

Lot 3 Fissure Sealing and the Targeted Approach to

Service Delivery

Oral Health Services Research Centre

User Group Members Dr Mary Ormsby Chair Dr Riana Clarke Joint secretary Dr Michael Mulcahy Joint secretary Dr Padraig Creedon Dr Nader Farvardin Dr Gerard Gavin DOH&C Dr Joe Green Dr Margie Houlihan Dr John Jones Dr Dympna Kavanagh Dr Maria Kenny Dr Stephen Mc Dermott Dr Mary O’Connor Dr Mary O’ Farrell Dr Dan O’ Meara Dr Colleen O’ Neill Dr Carmel Parnell Dr Matt Walshe

Project Team - OHSRC

Professor Denis O’Mullane - PI Dr Helen Whelton – Deputy PI Dr Rose Kingston Dr Evelyn Crowley Dr Paul Beirne Ms Jennifer Leyden Ms Elspeth Cameron

Format of Presentation:

Background to Lot 3 Targeting of Health Board Dental

Services Fissure Sealants Development of strategy for

needs assessment within HBDS Policy Issues relating to guidance

on fissure sealants in HBDS Further Research

Background to Lot 3

Two Strategies

Two distinct approaches to the control of illness (Rose 1985):

• Population approach– aims to control the occurrence of

new disease in a population

• High risk approach– identifies individuals at high risk of

disease and targets them for treatment and/or prevention

Reason for Targeting Services

• Early identification of those at high risk of disease; target for prevention and/or treatment

• Economics – rationing of services

These two issues provide rationale for current targeted approach to service delivery in HBDS

Fissure Sealants

“A fissure sealant is a substance that is placed in the pits and fissures of teeth in order to prevent the development of caries ”

Public Dental Service Reviews

The Leyden Report (1988)

• The adoption of a national strategy for the delivery of dental services to ensure an equal standard of service for all persons

• Recommended that specific classes in national schools be targeted for treatment & prevention and additional dental teams recruited to meet the needs of the children’s dental service

• 1st/2nd, 4th and 6th classes

National Survey Children’s Oral Health - 1984

• Decline in prevalence of dental caries

• 60% of total caries experience in perm teeth of 8-year-olds contributed by 1st perm molars

• Occlusal surfaces only involved in 50% of 1st perm molars affected by caries (Holland et al 1986)

Recommendation NSCOH 1984

• Increased use of fissure sealants in combination with fluoride will lead to substantial further reductions in dental caries

• Studies be undertaken to investigate cost-effectiveness in order to inform policy on the use of fissure sealants in HBDS

Dental Health Action Plan (1994)

• The health boards dental services were moving from a demand led service towards a targeted service with increasing emphasis on the treatment of special needs patients

• Dental Health Education and prevention given priority

Lot 3

Lot 3

Aims:

• To assess the current situation of targeting of general dental services in the Health Board

• To assess the current patterns of use of fissure sealants in the HBDS and their future use

Lot 3 - Methods

• Situation analysisInformation gathering (Literature Review)Review of existing servicesSecondary data analysis

• Consultation process

• Findings and Recommendations

• Information Dissemination

Lot 3 Related Projects

• National Survey Children’s Dental Health (Whelton et al 2002)

• An Evaluation of a fissure sealant programme in Co.Meath, Ireland (Parnell et al 2003)

Lot 3 Related Projects

• MDPH Projects:

−An audit of fissure sealing in the Eastern Health Board (Clarke 1999)

−An assessment of the use of the targeted approach in the HBDS (Mulcahy 2001)

−An economic evaluation of the use of dental hygienists in the fissure sealant programmes of the public dental service of the MidWestern Health Board Public Dental Services (O’ Connor 2002)

Lot 3

Caries Risk

% of total caries experience contributed by top 20% of

dmft/DMFT score

85%

65%55%

73%

60%54%

5 Year Olds 12 Year Olds 15 Year Olds

National Survey of Children's Oral Health 2002

None

Full

Caries Risk Assessment

• Difficult to predict despite many national and international studies

• Whelton (1989) and Kavanagh (1994)

• Two reasonably sensitive criteria:- Subjects with previous caries

experience- Clinician’s clinical opinion

Lot 3

Targeting

Targeting of Health Board Dental Services

• Wide variation between boards in the adoption of the targeted approach (Mulcahy 2001)

• Targeting particular classes unlikely to select appropriate “at risk” groups for treatment and preventive services

Targeting of school classes for fissure sealing

Cumulative Percentage of First Permanent Molars Erupted

0%10%20%30%40%50%60%70%80%90%

100%

4.0 6.0 8.0 10.0 12.0 14.0 16.0 18.0

Age (yrs)

Perc

ent E

rupt

ed Tooth_16

Tooth_26

Tooth_36

Tooth_46

Targeting of school classes for fissure sealing

Cumulative Percentage of Second Permanent Molars Erupted

0%10%20%30%40%50%60%70%80%90%

100%

4.0 6.0 8.0 10.0 12.0 14.0 16.0 18.0

Age (yrs)

Perc

ent E

rupt

ed

Tooth_17

Tooth_27

Tooth_37

Tooth_47

Conclusion

The unexpected wide variation in timing of eruption of 1st and 2nd permanent molars makes targeting of particular school classes for fissure sealing programmes problematic

Recommendations

• Need to re-direct and re-orientate services to being “ needs ” based

• Adoption of national needs assessment strategy which would include a national school dental screening programme

Major Findings Lot 3

Fissure Sealants

1) There is a wide variation in the extent to which different boards have put in

place fissure sealant programmes

• Level and pattern of use of fissure sealing varies widely within and between health boards

• No agreed policy on the use of fissure sealants in the HBDS

- Classes targeted

- Skill mix

- Blanket seal/ Targeted approach

% of 8-year-old children with at least one fissure sealant on their permanent teeth

by disadvantage status

0

20

40

60

80

100

ERHA MHB MWHB NEHB NWHB SEHB SHB WHB RoI

MC No MC Yes

% of 12-year-old children with at least one fissure sealant on their permanent

teeth by disadvantage status

0

20

40

60

80

100

ERHA MHB MWHB NEHB NWHB SEHB SHB WHB RoI

MC No MC Yes

% of 15-year-old children with at least one fissure sealant on their permanent

teeth by disadvantage status

0

20

40

60

80

100

ERHA MHB MWHB NEHB NWHB SEHB SHB WHB RoI

MC No MC Yes

National Survey Children's Oral Health 2002

2) A very high proportion of dental decay occurs in pits and fissures

0

20

40

60

80

100

8 yearolds

12 yearolds

15 yearolds

% caries in pits and fissures of permanent molars

% caries

3) Fissure sealants are effective at preventing pit and fissure caries

• “Sealing with resin based sealants is a recommended procedure to prevent caries of the occlusal surfaces of permanent molars” – Cochrane Systematic Review 2004

• “Sealants are highly effective in preventing dental caries in pits and fissures of teeth when applied by trained operators in clinical trials and community health programmes” – BSPD 2000

• “After 4.5 years sealed permanent molar teeth of children 5-10 years had reduction of decay in over 50% of biting surfaces compared to teeth without sealants” - Cochrane Systematic Review 2004

4) Pits and fissures remain at risk of caries for long periods of time

• Slowing of the rate of progression

• Change in caries risk status

• “All vunerable pits and fissures should be considered for fissure sealing irrespective of the length of time they have been in the mouth” – Locker (2003)

5) Fissure sealants can be applied in at-risk, caries free teeth and as therapy for incipient lesions

6) Fissure sealants are best used as part of an overall preventive programme

7) Fluoride has limited effect in preventing pit and fissure caries

8) Application of fissure sealants should be based on individuals, tooth and surface risk

9) The key to sealant success is sealant retention

• Gillcrist et al 1998 - “ The effectiveness of a dental sealant depends upon its long term clinical retention and regular maintenance ”

sealant retention sealant success

• As long as a fissure sealant remains intact, that surface will be protected from initiation of dental caries or progression of existing incipient caries

10) Regular assessment of fissure sealants necessary to monitor

retention

• Most sealant failures occur within 6-12 months of placement (1995 workshop)

• Sealants should be regularly reviewed and repaired or replaced as necessary to ensure continued success

Development of a Strategy for Needs Assessment and

use of Fissure Sealants within the HBDS

The following issues need to be taken into consideration in development of future strategy:

• Children with extensive decay in their primary teeth should have all 1st permanent molars sealed as soon as possible after eruption

• Children may need to be examined using agreed criteria, when they are in senior infants, 1st and 2nd class to determine risk status of the 1st permanent molar

• Any child in any class with dmft/DMFT > 1 necessitates full examination and treatment including fissure sealing all sound molars

• All children with special needs or who are disadvantaged should be prioritised for oral health care

• Any child with dmft/DMFT > 1 should be screened in 6th class, 1st and 2nd year to ensure sealing of second permanent molars

• All teeth which are fissure sealed should be reviewed within one year of placement and thereafter at regular recall visits

• Appropriate recall intervals will take into consideration the recent NICE Clinical Guideline on Dental Recall (Oct 2004)

• Any screening of any child at any age implies all treatment needs should be identified and treatment provided, within a reasonable period of time

Policy Issues relating to guidance on Fissure Sealants

in HBDS

• Annual screening/examination/recall of most children from senior infants to 2nd/3rd of secondary school year to identify children and teeth “at risk”

• Specific training criteria for dental personnel in identification of “at risk” individuals

• Specific training criteria for dental personnel in application and maintenance of fissure sealants

• Need for a robust IT system to monitor sealant placement and effectiveness

• Recall interval for children under 18 years < 12 months (NICE Guidelines)

• Need for appropriate skill mix within HBDS

Other Topics under Lot 3

Other Lot 3 Topics

• The management of traumatic injuries to incisors

• The management of caries in primary teeth

Trauma

The percentage of children and adolescents with trauma to one or more of their front teeth has not improved since 1984All HB 8 12 15

1984 1.7 6.4 8.7

2002 1.8 6.4 9.3

Trauma

The percentage of children and adolescents affected by trauma who have at least one traumatised permanent incisor untreated has not improved since 1984

0102030405060708090

100

8 years 12 years 15 years

1984

2002

Caries in primary teeth

Wide variation between health boards in the percentage of untreated total decay experience in primary teeth

0

20

40

60

80

100

ERHA MHB MWHB NEHB NWHB SEHB SHB WHB RoI

Untreated caries as a percentage of total caries experience (vd/vdmft)

MC No MC yes

Caries in primary teeth

Need for longitudinal studies to monitor the consequences of a treatment vs non-treatment approach of primary teeth on the general health and oral health of children

Further Research

Further Research

• Required in area of fissure sealants and targeting of health board dental services

• Recommended further research: eg. – Eruption times 1st and 2nd permanent

molars– Present fissure sealant retention rates

in HSE areas– Pilot study of proposed national

screening programme– Causes of traumatised primary and permanent incisors

Acknowledgement

The contribution of the User Group to the successful completion of the Lot 3 project is acknowledged