Fluoride and sealants: How these preventive tools are helping our pediatric patients

As a dental hygienist who has worked with children in school-based care for the last four years, I always look forward to February—Children’s Dental Health Month. So many of us devote our time to educating students about oral health who may not hear about it otherwise, by visiting preschools, elementary schools, middle and high schools, as well as after-school programs. Hygienists across the country are taking advantage of the school setting to spread the word about prevention.

While February is a great time to focus on education for the kiddos, it is also the perfect time to take a dive into the preventive measures we can offer these children. Two of the best tools we have are dental sealants and fluoride varnish. Both preventive measures have great benefits, and their effectiveness has been proven. Dental sealants and fluoride treatments have been used for decades to combat childhood tooth decay.

Before we look at these preventive measures, though, let’s evaluate the cariogenic process and the lasting impact it has on the pediatric population. It is important to keep the current times in mind. COVID-19 has presented more challenges than we can count, and that includes school-based care and children coming into our operatories for the care they so desperately need. Now more than ever, we need to look at what we can offer the children we serve to help keep them cavity-free.

Dental decay continues to be one of the most prevalent chronic childhood diseases in the United States, even more common than asthma.¹ This is a statement that we all, as hygienists, see firsthand year after year. Despite the fact that we are living in a time when technology is at our fingertips and advances in dentistry and dental hygiene continue, dental caries still remains a major problem for children in our country. And it is a problem that is completely preventable.

We all know that the caries process is multifactorial, and it is an uphill battle for high-risk children to change their home habits. According to the Centers for Disease Control and Prevention (CDC), about one of five (20%) children ages 5–11 have at least one untreated decayed tooth.¹ One of seven (13%) adolescents ages 12–19 have at least one untreated decayed tooth.¹ Children 5–19 from low-income families are twice as likely (25%) to have cavities, compared with children from higher-income households (11%).¹ Any hygienist working with school-aged children knows that untreated tooth decay affects so much more than the child’s oral health. Children who suffer from recurrent decay or early childhood caries also deal with nutrition issues, speech problems, inability to sleep, and issues concentrating in the classroom.

The Children’s Dental Health Project reported a North Carolina study finding that children with poor oral health were three times more likely than their counterparts to miss school as a result of dental pain.² Many of us know from personal experience that low-income or immigrant children are at highest risk. The Surgeon General’s Report on Oral Health indicates Hispanic and non-Hispanic black children are at the highest risk of developing dental caries.³ Proper preventive measures offer hope for these children, and as dental hygienists, we are fortunate to be able to offer these services.

Dental sealants

Dental sealants are thin plastic coatings that protect the chewing surfaces of children’s back teeth from tooth decay. Many of us can remember meeting our sealant competency in dental hygiene school, but that may have been the last time we placed sealants. We probably did not realize when we were learning to place sealants that they are one of the most effective measures to help high-risk children battle dental decay. Sealants fill in the grooves and help keep debris and bacteria out of the occlusal surface and buccolingual pits.⁴

There are a number of sealant materials on the market, and the placement technique varies based on the type of sealant. Many sealant materials still require cleaning of the occlusal surface, isolation, drying, sealant placement, and sometimes light curing of the sealant. Some sealant materials require acid-etching, while some do not. Other materials recommend the use of a bonding agent or adhesive; it all depends on the material being used and the manufacturer’s instructions.⁵

Research is varied when it comes to which sealant material is best. According to a study published by the Journal of the American Dental Association, when looking at various sealant materials, there was not enough evidence to report any of them being superior.⁵ It is important to note that some hygienists are taking a closer look at their sealant materials since COVID-19. Many are trying various glass ionomer sealant materials that do not require etching and bonding. Glass ionomer sealants also do not require a dry field, which means that you do not have to use high-volume suction. Glass ionomer sealants can be a great option in the outreach setting due to the fact that they do not require a dry field and they also have fluoride-releasing properties.

Regardless of the sealant material, let’s take a closer look at the effectiveness of dental sealants for pediatric patients. According to the American Journal of Public Health, dental sealants have been commercially available since 1971.⁶ Evidence suggests that pit and fissure sealants are effective in preventing caries in children and adolescents, compared to no sealants at all.

According to the CDC, dental sealants prevent 80% of cavities in the back teeth, where nine in 10 cavities occur.⁷ There was a 70% increase in sealant use in low-income children from the years 1999–2004 and 2011–2014.⁷ Almost one million cavities were prevented in children who received sealants.⁷ That is impressive data, and those of us working in school-based care know how important it is to get sealants on high-risk children as soon as possible.

Although sealants are making great strides in preventing decay, disparities still exist. In that same report by the CDC, it was reported that about 60% of children ages 6–11 don’t get sealants, and children from low-income families are 20% less likely to get dental sealants than children from higher-income families.⁷

Fluoride varnish

Fluoride varnish is another preventive measure that is highly effective in the fight against childhood caries. Fluoride treatments have been used as prevention for a long time, and they are an extremely effective and economical measure to help the pediatric population.

Fluoride treatments have certainly evolved through the years. I am certain that many of us remember the four-minute fluoride treatments that were the standard many years ago. There have been gels, foams, and now the mostly commonly used is fluoride varnish.

Most varnishes today are 5% sodium fluoride, and they come in a variety of flavors and packaging. According to the United States Preventive Services Task Force, application of fluoride varnish is recommended every three to six months for children younger than age 6.⁸ Not only can a fluoride varnish application help prevent caries; it can also reverse early caries white spot lesions. Regular applications have also been known to decrease caries in the permanent dentition.

Patient acceptance varies, but for the most part it is high. There are many varnish flavors on the market, which helps with patient acceptance. There is even a salted caramel flavor now; the options seem endless.

Ease of application contributes to patient acceptance. Varnish takes less than a minute to apply, which is great for pediatric patients. Many medical providers now apply fluoride varnish in their offices, so this is a great opportunity for medical-dental integration. Additionally, many Head Start programs have hygienists who come in and offer screenings and fluoride varnish applications. The ease of application and the low cost allow fluoride varnish to be applied in numerous nontraditional settings.

We can see what an asset dental sealants and fluoride varnish are in the battle against childhood caries. Of course, many factors must be considered when it comes to helping the pediatric population combat decay. Some of those factors are ones that we cannot control. We can’t force children or parents to make the right food and drink choices or to brush and floss at home. But applying fluoride varnish and placing sealants are things we can do, and both of these preventive measures are excellent weapons against childhood caries. Children’s Dental Health Month is a great time to focus on childhood caries and ways we can help the children we serve.

If you do not work with the pediatric dental population, perhaps this article will inspire you to engage with the kids in your community. COVID-19 has changed the way we engage with patients, but it is still vital that we provide critical oral health information. This is where we can get creative in how we get our preventive message out to patients. Many hygienists are using YouTube to create avenues for oral health instruction and then offering this education to schools and Head Start programs. The opportunities are endless, so let’s join in! 

References

1. Children’s oral health. Centers for Disease Control and Prevention. Division of Oral Health. National Center for Chronic Disease Prevention and Health Promotion. Updated December 10, 2020. https://www.cdc.gov/oralhealth/basics/childrens-oral-health/index.html
2. The state of dental health. School years and beyond. Children’s Dental Health Project. https://www.cdhp.org/state-of-dental-health/schoolandbeyond
3. Disparities in oral health. Centers for Disease Control and Prevention. Division of Oral Health. National Center for Chronic Disease Prevention and Health Promotion. Updated May 1, 2020. https://www.cdc.gov/oralhealth/oral_health_disparities/index.htm
4. Dental sealants. National Institute of Dental and Craniofacial Research. Updated October 2018. https://www.nidcr.nih.gov/health-info/sealants
5. Wright JT, Crall JJ, Fontana M, et al. Evidence-based clinical practice guideline for the use of pit-and-fissure sealants: a report of the American Dental Association and the American Academy of Pediatric Dentistry. J Am Dent Assoc. 2016;147(8):672-682.e12. doi:10.1016/j.adaj.2016.06.001
6. Weintraub JA, Stearns SC, Rozier RG, Huang C-C. Treatment outcomes and costs of dental sealants among children enrolled in Medicaid. Am J Public Health. 2001;91(11):1877-1881. doi:10.2105/ajph.91.11.1877
7. Dental sealants prevent cavities. Effective protection for children. CDC Vitalsigns. Centers for Disease Control and Prevention. October 2016. https://www.cdc.gov/vitalsigns/pdf/2016-10-vitalsigns.pdf
8. Kim P, Daly JM, Berkowitz S, Levy BT. Use of the fluoride varnish billing code in a tertiary care center setting. J Prim Care Community Health. 2020;11:2150132720913736. doi:10.1177/2150132720913736

Brooke Crouch, RDH, is a remote supervision dental hygienist with clinical experience spanning private practice to public health and including a state agency and federally qualified health center. She serves as vice president of the American Mobile & Teledentistry Alliance and is an educator and mobile dentistry consultant who is passionate about advocating for policy changes to increase access to care. Crouch currently serves on several clinical advisory, oral health action, and community-based boards and committees throughout Virginia. For more information, contact her at [email protected].