Seal America, The Prevention Invention
Seal America, The Prevention Invention

Step 1
Getting Started

A school-based dental sealant program can be initiated at the state, county, community, or school level. Programs are often spearheaded by an individual or small group that participates in the planning process or delegates others to take part in it.

The process of establishing a school-based dental sealant program involves several important steps, including forming a planning committee, conducting a needs assessment, and determining the geographic area, target population, and number of students eligible for the program.

Planning Committee

The first step in establishing a school-based dental sealant program is to form a planning committee consisting of several members. The purpose of this committee is to design the program and to serve as the core of a larger advisory group (see Step 2, Gaining and Maintaining Community Support).

Planning committee members could include

  • A school nurse or health advocate
  • A public health official
  • An oral health professional
  • A state or local oral health coalition member

Needs Assessment

Once the planning committee has been formed, the needs, interests, and resources of the community should be assessed to determine whether establishing a school-based dental sealant program is appropriate. The manual, Assessing Oral Health Needs: ASTDD Seven-Step Model, rev ed. can be a valuable resource in conducting this needs assessment.

There are many ways to conduct a needs assessment. Simple methods such as using information from questionnaires can be used, or more sophisticated methods such as taking data from epidemiologic surveys can be employed.

Comparing national and state oral health data to community oral health data can provide a powerful rationale for why a school-based dental sealant program should be established. This is especially effective if data from the community needs assessment indicate that tooth decay rates are the same as or higher than national or state rates.

Data Sources

Centers for Disease Control and Prevention National and State Data
National and state data are available from CDC. The National Oral Health Surveillance System, a collaborative effort between CDC's Division of Oral Health and the Association of State and Territorial Dental Directors (ASTDD), is designed to monitor the burden of oral disease, use of the oral-health-care-delivery system, and status of community water fluoridation on both a national and a state level. Oral health indicators for third-grade students include caries experience, untreated tooth decay, and dental sealants on at least one permanent molar tooth.

The National Health and Nutrition Examination Survey
The National Health and Nutrition Examination Survey (NHANES) is a program of studies designed to assess the health and nutritional status of children and adults in the United States. NHANES offers national data on the prevalence of tooth decay, untreated tooth decay, and dental sealants for children and adolescents.

Centers for Disease Control and Prevention Online Resource Library
CDC also offers an online resource library that provides links to CDC's Division of Oral Health's recent press releases, fact sheets, journal articles, Morbidity and Mortality Weekly Report publications, and other materials.

State and National Data from School-Based Dental Sealant Programs
State and national data derived from the implementation and evaluation of school-based dental sealant programs provide evidence on what can be achieved by targeting children and adolescents from families with low incomes or other populations. For example, an analysis of Ohio's school-based dental sealant programs reports the positive impact these programs had on reducing racial and economic disparities in dental sealant prevalence among children and adolescents.2

Other Data Sources
State oral health programs may be an important resource for data on caries experience, sealant prevalence, and access to care. In addition, some states collect county- and city-level data. Another potential source of data is the school district, especially if school nurses or other health professionals conduct annual health screenings.

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Geographic Area

The geographic area that the school-based dental sealant program will serve can be the area that the planning committee has either an interest in or a responsibility for serving. The area could be specific neighborhoods, school systems, a city, a county, several counties, or, in some instances, an entire state.

Target Population

It is important to define the target population for the school-based dental sealant program. Needs-assessment results can help in defining the target population. Most school-based dental sealant programs use income and school grade as a basis for targeting. Some programs, on the other hand, operate with a philosophy that every child or adolescent, regardless of income level, should have the opportunity to receive dental sealants, and they use only school grade as a basis for targeting.

Recommendations contained in the report, Workshop on Guidelines for Sealant Use: Preface and Recommendationsprovide step-by-step instructions for selecting approaches to increase dental sealant prevalence.3 The planning committee should consult these recommendations when deciding whether school-based dental sealant programs are appropriate for specific population groups.

Another helpful resource in defining the target population is ASTDD's Proven and Promising Best Practices for State and Community Oral Health Programs, which includes information on surveillance systems and school-based dental sealant programs.4

Income Level

Eligibility for free and reduced-price meals from the U.S. Department of Agriculture's (USDA's) National School Lunch Program (NSLP) has been used as a proxy for income and increased risk for tooth decay. USDA's NSLP provides free or reduced-price meals to students whose families meet income eligibility guidelines. School-based dental sealant programs frequently target schools in which at least 50 percent of students are eligible for USDA's free and reduced-price meals.5

Once schools have been selected for inclusion in the school-based dental sealant program, a decision needs to be made about which students at the school are eligible for the program. Possibilities include

  • All students
  • Students who qualify for USDA's free or reduced-price meals
  • Students who do not have a dentist or a dental home
  • Students who are enrolled in or eligible for Medicaid or CHIP
  • Students who do not have dental insurance

In some instances, schools are unwilling to single out specific students because of the potential for stigmatizing those selected for the program or because the school philosophy supports providing services to all students. Therefore, some programs make dental sealants available to all students in targeted grades.

When using income as a method of targeting students for a school-based dental sealant program, it is important to consider differences between urban and rural areas in the geographic distribution of families with low incomes.

In urban areas, families with low incomes tend to cluster in certain neighborhoods. As a result, schools near or in these neighborhoods frequently have high percentages of students from families with low incomes.

In rural areas, families with low incomes tend to be spread more evenly throughout the school system. As a result, while large numbers of families with low incomes may reside in a rural county, it is unlikely that schools in that county will have particularly high percentages of students from families with low incomes. To address this issue, some statewide dental sealant programs target rural areas using median family incomes and then include all schools in a school system in which median family income is below a certain level.

Some communities have large numbers of immigrants, refugees, or undocumented individuals. These groups may not qualify for USDA's free or reduced-price meals. Flexibility should be built into eligibility criteria so that these groups are not excluded from school-based dental sealant programs. In many instances, they have the greatest need.

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School Grade

Pit-and-fissure caries are most likely to occur in first and second molars.6 Most dental sealant programs, therefore, target these teeth.

Second grade seems to be the most appropriate grade during which to seal the most erupted, noncarious first molars.7 Table I shows the likelihood of the occlusal surfaces of first and second molars being sufficiently erupted for sealant application at different grade levels. The eruption time of the second molar, however, is quite variable, erupting between sixth and eighth grade, with females preceding males and African-Americans preceding whites.

Table I: Availability for Sealant Application of Occlusal Surfaces of First and Second Permanent Molar Teeth, According to Grade Level, Ohio 1987–88

Percentage of Students with All Four Occlusal Surfaces Sufficiently Erupted for Sealant Application and with No Occlusal Surfaces Sufficiently Erupted +

  First Permanent Molars Second Permanent Molars
Grade Level All Four % None % All Four % None %
1 57.2 18.8    
2 88.5 1.8    
3 96.8 0.0    
6     23.6 37.6
7     55.5 11.8
8     75.8 3.6

+“Sufficiently erupted” means that the occlusal surface is completely exposed and clear of gingival tissue, but the term does not indicate eruption status of buccal and lingual surfaces with pits and fissures, which can contribute to overall caries levels.

Adapted, with permission, from Kuthy, RA, Ashton, JJ. 1989. Eruption pattern of permanent molars: Implications for school-based dental sealant programs. Journal of Public Health Dentistry 49(1):7–14.

For a school-based dental sealant program to operate as efficiently as possible, when identifying what grade or age group to target, it is important to strike a balance between the number of eligible teeth to be sealed, the likelihood that students will participate in the program, and available resources. The following factors should be considered:

  1. Tooth-eruption rates. Many programs target only second-grade students, because rates of erupted, non-carious teeth tend to be greater than in the higher grades. Less than 60 percent of all first-grade students' first molars are fully erupted. The probability of all four first molars being fully erupted among third-grade students is high (89 to 97 percent); however the possibility of those teeth having decay is higher than among students in lower grades. Targeting students in higher grades (grades 6, 7, or 8) is more difficult because the age by which all four first molars have erupted varies widely.
  2. Susceptibility. Looking at caries prevalence over time based on tooth type, permanent first and second molars are more susceptible to tooth decay than other tooth types (e.g., canines, premolars, incisors).7
  3. Risk. Children and adolescents ages 6–19 from families with low incomes are twice as likely to have untreated tooth decay as are their counterparts from families with higher incomes.1
  4. Participation rates. Students' participation rates tend to be lower in middle school and high school than in elementary school. Failure to return signed consent forms, peer pressure, and fear of dentistry are potential reasons for low rates of participation.
  5. School structure. When targeted grades are in the same building, it is more efficient to reach students for dental sealant placement as well as to conduct follow-up assessment. Some school systems offer kindergarten through grade 8, while others offer kindergarten through grade 5, with middle school offering grades 6 through 8 and high school offering grades 9 through 12. Some school systems, on the other hand, include schools that are divided into a small number of grades (e.g., kindergarten through grade 3, grades 4–6, grades 7–8, grades 9–12). This organizational structure makes it difficult to target students in grades 6–8.
  6. Class schedules. It can be more difficult to implement dental sealant programs in schools where each student has an individual schedule and moves from class to class.

After considering these factors, most programs choose to target sixth-grade students, rather than seventh- or eighth-grade students. Those that target students in higher grades find that, while a greater percentage of second permanent molars have erupted among this age group, fewer students have participated in the program. Participation rates vary among programs, but the pattern of participation by grade is consistent. Second-grade students are by far the best participators. The participation rate for sixth-grade students is usually 10–15 percentage points behind that of second-grade students, and the rate for seventh- and eighth-grade students is 15–20 percentage points behind that of sixth-grade students.

Number of Students Eligible for the Program

After the geographic area has been defined and the targeting method has been determined, the planning committee should estimate the number of students eligible for the program by obtaining census information from schools in the defined geographic area. It is critical to obtain a good estimate of the number of students eligible for the program to continue the planning process, particularly when the program is purchasing equipment and supplies and hiring staff.


  1. Dye BA, Tan S, Smith V, Lewis BG, Barker LK, Thornton-Evans G, Eke PI, Beltran-Aguilar ED, Horowitz AM, Li CH. 2007. Trends in Oral Health Status: 1988–1994 and 1999–2004. Hyattsville, MD: National Center for Health Statistics.
  2. Centers for Disease Control and Prevention. 2001. Impact of targeted, school-based dental sealant programs in reducing racial and economic disparities in sealant prevalence among schoolchildren—Ohio, 1998–1999. Morbidity and Mortality Weekly Report 50(34):736–738.
  3. Workshop on Guidelines for Sealant Use. 1995. Workshop on guidelines for sealant use: Preface and recommendations. Journal of Public Health Dentistry. 55(5):261–273. Special issue.
  4. Association of State and Territorial Dental Directors. Best Practice Approach Reports [website]. Best Practice Approach: School-based Dental Sealant Programs.
  5. Li SH, Kingman A, Forthofer R, Swango P. 1993. Comparison of tooth surface-specific dental caries attack patterns in US schoolchildren from two national surveys. Journal of Dental Research 72(1):1398–1405.
  6. Kuthy RA, Ashton JJ. 1989. Eruption pattern of permanent molars: Implications for school-based dental sealant programs. Journal of Public Health Dentistry 49(1):7–14.
  7. Macek MD, Beltran-Aguilar ED, Lockwood SA, Malvitz DM. 2003. Updated comparison of the caries susceptibility of various morphological types of permanent teeth. Journal of Public Health Dentistry 63(3):174–182.

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