Best Practice Approaches for State and Community Oral Health Programs

Transcription

1 Best Practice Appraches fr State and Cmmunity Oral Health Prgrams A Best Practice Apprach Reprt describes a public health strategy, assesses the strength f evidence n the effectiveness f the strategy, and uses practice examples t illustrate successful/innvative implementatin. I. Best Practice Apprach Schl-based Dental Sealant Prgrams Summary f Evidence Supprting Schl-based Dental Sealant Prgrams Research +++ Expert Opinin +++ Field Lessns ++ Theretical Ratinale +++ See Attachment A fr details. II. Descriptin A. Dental Sealants Dental sealants are clear r paque plastic materials applied t the pit-and-fissure surfaces f teeth t prevent decay (dental caries). Sealants prvide a physical barrier that prevents debris and decaycausing bacteria frm cllecting in the pits and fissures f vulnerable teeth (mainly mlars). These areas are ften the first and mst frequent sites t be affected by tth decay in children and adlescents. Natinal estimates shw that as much as 90% f all dental caries in schlchildren ccurs in pits and fissures (1). The permanent first and secnd mlars are at the highest risk fr tth decay (2). T be mst effective, sealants shuld be placed n teeth sn after they erupt. Sealants are helpful fr persns at increased risk fr tth decay such as thse with medical cnditins assciated with higher caries rates, children wh have experienced extensive caries in their primary teeth, and children wh already have incipient caries in a permanent mlar tth (2). Sealants are clinically effective in preventing tth decay as lng as the sealant is retained n the tth (2-4). Sealants may need t be evaluated peridically and re-applied as necessary (3). Studies have evaluated the placement f sealants n tth surfaces with caries (2). Heller et al. (5) evaluated the effect f sealants placed n permanent first mlar teeth thrugh a schl-based prgram after five years. The 5-year tth decay rate was lwer fr sealed tth surfaces with incipient caries cmpared t unsealed tth surfaces (10.8 percent versus 51.8 percent). Mertz- Fairhurst et al. (6) reprted a 10-year study that shwed caries did nt prgress under a dental sealant placed ver cavitated lesins that were n mre than halfway thrugh the dentin f the tth. The mst recent Natinal Health and Nutritin Examinatin Survey (NHANES) shwed that during , 18.5% f U.S. children, ages 5-17, had ne r mre sealed permanent teeth. Mlar teeth were the mst frequently sealed. A significantly higher percentage f nn-hispanic whites had sealants in cmparisn with their nn-hispanic black and Mexican-American cunterparts (7). Schl-based Dental Sealant Prgrams 1

2 B. Dental Sealant Prgrams Dental sealant prgrams generally prvide sealants t vulnerable ppulatins less likely t receive private dental care, such as children eligible fr free r reduced-cst lunch prgrams (2). There are variatins in hw dental sealant prgrams are designed: Schl-based prgrams are cnducted cmpletely within the schl setting, with teams f dental prviders (dentists, dental hygienists and dental assistants) utilizing prtable dental equipment r a fixed facility within the schl setting. Schl-linked prgrams are cnnected with schls in sme manner but deliver the sealants at a site ther than the schl (i.e., a clinic r private dental ffice). Schl-linked prgrams may present infrmatin, distribute cnsent frms and cnduct dental screening at schls. Hybrid prgrams incrprate schl-based and schl-linked cmpnents (sme schls have schl-based and sme have schl-linked services). Synpses f State and Territrial Dental Public Health Prgrams shwed that in , 35 states and 4 territries reprted having prgrams fr dental sealants (in ne r mre f the prgram design variatins described abve). The states include: AL, AZ, CA, CO, CT, GA, ID, IL, IN, IA, KY, LA, ME, MD, MA, MN, MO, NE, NV, NH, NJ, NM, NY, NC, ND, OH, OK, OR, RI, UT, VT, VA, WV, WI, and WY. The territries include American Sama, Guam, N. Mariana Islands, and Republic f Palau (8). The 2003 Oral Health Reprt Card (9), published by the Oral Health America Natinal Grading Prject t call greater plicy attentin t ral health needs, graded states n their statewide sealant prgrams. The grading is based n the percentage f a ppulatin f caries-risk children (e.g., minrity, lw-incme, Medicaid eligible, lunch prgram eligible and/r withut insurance) served by the sealant prgram. The fllwing was reprted fr the states and District f Clumbia: 4 states have a statewide sealant prgram targeting and serving ver 35% f a distinct ppulatin f caries-risk children [Grade=A] 12 states have a statewide sealant prgram targeting and serving 20-35% f a distinct ppulatin f caries-risk children [Grade=B] 9 states have a statewide sealant prgram targeting and serving 5-19% f a distinct ppulatin; r a substantial targeted reginal prgram exists and is reaching ver 30% f the caries-risk ppulatin [Grade=C] 12 states have a statewide sealant prgram targeting and serving less than 5% f a distinct ppulatin f caries-risk children [Grade=D] 12 states have n existing statewide sealant prgram [Grade=F] 2 states withut infrmatin C. Schl-based Dental Sealant Prgrams A schl preventive ral health prgram may incrprate several elements, such as ral health educatin, dental screenings, referral fr dental treatment, fluride muthrinsing and sealant applicatins. Primary dental care prgrams in schl settings will als apply sealants as part f basic Schl-based Dental Sealant Prgrams 2

3 restrative and preventive dental treatment. This best practice apprach reprt, hwever, will describe nly schl-based prgrams fr which sealant applicatin is the primary prgram bjective. Schl-based dental sealant prgrams seek t assure that children receive a highly effective but underutilized dental preventin service thrugh a prven cmmunity-based apprach. Schl-based sealant prgrams generally are designed t maximize effectiveness by targeting high-risk children. High-risk children include vulnerable ppulatins less likely t receive private dental care, such as children eligible fr free r reduced-cst lunch prgrams. Children and their parents are made aware f dental sealants, their value and the availability f sealants thrugh the schl prgram. Once signed parental cnsent frms have been returned, children are evaluated fr their sealant needs and dental prfessinals place the sealants. Usually dentists examine the children and dental hygienists apply the sealants. Schl-based sealant prgrams need t address the unmet dental care needs f the children seen and assure quality f care by prviding fllw-up evaluatin and repair f the sealants placed thrugh the prgram. A state dental prgram s rle in schl sealant prgrams may take the frm f: (a) prviding direct service delivery, (b) funding grants r cntracts t deliver sealants, (c) managing a state-level prgram that des nt prvide direct service but pay fr services such as thrugh vuchers, (d) setting standards fr lcal direct service sealant prgrams, and/r (e) facilitating and prmting private-public sealant prgram partnerships (e.g., schls and dental scieties). The fllwing descriptin f a schl-based dental sealant prgram shws the attributes f a direct service delivery prgram, whether perated by a state r lcal agency r an rganizatin: 1. Delivers sealants t large numbers f high-risk children with susceptible permanent mlar teeth. There are three elements t this attribute: The prgram, as a whle, shuld serve an area that has a critical mass f children that meet its eligibility criteria. Such areas wuld include urban neighbrhds r rural cunties. The children served by the prgram shuld be high-risk. Generally, eligibility fr the free r reduced cst schl lunch prgram (185% f the federal pverty guideline) has been used as a prxy fr incme and increased risk f untreated decay. Children frm lw incme families have been shwn t be less likely t receive dental care than children whse families d nt meet the lunch prgram criteria. Lcal standards will determine the acceptability f targeting children rather than schls. In many lcales, ffering a sealant prgram t nly children n the lunch prgram is viewed as stigmatizing and, therefre, unacceptable. Targeting schls based n the prprtin f lunch prgram-eligible children, hwever, is generally acceptable. A minimum f 50 percent f the student enrllment being eligible fr the lunch prgram is a cmmn benchmark fr schl eligibility. Typically, sealant prgrams target children in the secnd grade (fr sealing the first permanent mlars) and sixth grade (fr sealing the secnd permanent mlars). Targeting these grades maximize the availability f susceptible mlar teeth. In this scenari, sixth grade is a cmprmise between maximizing participatin (which drps ff dramatically in Middle Schl and Junir High Schl) and maximizing the number f erupted, caries-free secnd mlars. 2. Maximizes prgram efficiency. There are tw elements t efficiency: Schl-based Dental Sealant Prgrams 3

4 The prgram establishes an adequate supply f available children and maintains their flw int the sealant placement prcess. Schl-based prgrams may be mre efficient than schl-linked prgrams in that they minimize the amunt f time away frm class and tend t maximize parent willingness t enrll children in the prgram. Furthermre, if a child is absent frm schl, n time is lst in calling the next child ut f class. These elements wrk tgether t ensure a cntinuus flw f children int the sealant placement prcess. The prgram perates the sealant placement prcess in the least expensive and mst prductive fashin pssible while delivering a quality prduct. Experienced schl-based dental sealant prgram teams can generally prvide sealants fr 20 r mre children per day. Prgrams must cmply with state laws regarding delegable prcedures and the need fr dentists t prvide the initial screening t determine which teeth are t be sealed. Efficient use f resurces generally directs a prgram t hire the least expensive persnnel categry permitted under state law. The prgram, hwever, must prvide adequate training and quality assurance. Sealants are mre efficiently applied by a 4-handed technique that requires a 2-persn team (e.g., a dental hygienist and a dental assistant). 3. Re-examines children within ne year after initial sealant placement. At this time, newly erupted teeth may be sealed, and previusly placed sealants may be repaired r reapplied, as necessary. Sealant failure (full r partial lss f the sealant) generally results frm salivary cntaminatin at the time f sealant placement. Such failure ccurs sn after sealant placement (within mnths). Typically children wh received sealants in grade 2 are re-screened in grade 3. Likewise 6th graders are re-screened in grade Maintains a quality assurance system. A quality sealant prgram will assure cnfidentiality and treat children and families respectfully. Tw primary elements f quality assurance are: Assuring technical quality f the sealants applied. Technical quality generally refers t a high rate f retentin fr sealants placed and can be assessed thrugh analyzing sealant retentin data frm fllw-up screenings. Als, retentin may be assessed n a shrtterm basis by returning t a sample f schls within 1-2 mnths f sealant placement r during the next schl year and re-checking a small number f children (e.g., children). Assuring apprpriateness f the prgram. Apprpriateness can be evaluated by analyzing prgram participatin t ensure children and schls in the prgram meet its eligibility criteria. Additinally, prgrams shuld assure cmpliance with applicable laws and prfessinal standards and guidelines, including infectin cntrl. 5. Identifies children with treatment needs and assures that they receive apprpriate dental care. When assessing the need fr sealants, examiners in schl-based sealant prgrams typically identify children with treatment needs, such as untreated decay, and ntify parents and schl nurses. Assuring that the children receive apprpriate dental care is, perhaps, the mst difficult aspect f a schl-based sealant prgram. It is nt uncmmn fr a sealant prgram t find 30-50% f the children screened t be in need f dental care (e.g., restrative, rthdntic) that is Schl-based Dental Sealant Prgrams 4

5 beynd the scpe f the sealant prgram. Ideally, these treatment needs will be met thrugh linkages t public clinics r private prviders. In reality, this is a difficult situatin because many children in schl-based sealant prgrams have limited access t care. In additin, sme families may place a lw pririty n seeking dental care fr their children in light f ther cmpeting demands. 6. Maintains descriptive prgram data. Prgram data shuld reflect the prgram s ability t reach its gals and bjectives. Descriptive prgram data can include: An estimate f the number and percentage f all high-risk children in the state wh receive sealants thrugh the prgram. An estimate f the percentage f eligible schls (e.g., 50% f students n lunch prgram) in the state served by sealant prgrams. An estimate f the cst per child screened (including csts f referrals fr care) and cst per child wh receives sealants will give gd benchmarks fr prgram efficiency. Methds used by states t estimate cst per child r per sealant are nt standardized (e.g., cst f equipment, travel and/r administrative time may r may nt be included in estimating cst). Nte that depending n the tth selectin criteria, assessment f the number f teeth sealed r the cst per tth sealed shuld identify if lw risk teeth, such as premlars, are rutinely sealed. Rates f participatin r parental cnsent received. A cmparisn f the percentage f children in grades targeted fr sealant applicatins wh need dental care with the percentage f the same chrt the fllwing year wh need dental care (e.g., cmparing grade 2 with grade 3 r grade 6 with grade 7). 7. Is sustainable. The prgram s sustainability can be demnstrated by the prgram having an established track recrd r a reasnable plan fr cvering prgram expenses. This may include a line item in the state r municipal budget, a mechanism fr cllecting Medicaid incme, r recurring grant funding. Sme state agencies may enter int creative partnerships in rder t sustain the prgram. III. Guidelines & Recmmendatins frm Authritative Surces Healthy Peple 2010 Oral Health Objective 21-8 calls fr 50 percent f eight and 14 year-ld children t have sealants n their permanent mlar teeth (10). The Healthy Peple 2010 sealant bjective and sealant prgrams fcus n permanent mlars because caries risk n ther teeth with pits and fissures is cnsiderably lwer. Althugh sealants can be placed n children s premlars, maxillary incisrs and primary mlars, the situatins in which such use wuld be apprpriate are limited. Schl-based Dental Sealant Prgrams 5

6 The Surgen General s Reprt n Oral Health fund that studies suggest that sealants are an efficient use f resurces when used in ppulatins with higher-than-average disease incidence rates and when sealants are placed n teeth at highest risk fr caries (2). The 1995 Wrkshp n Guidelines fr Sealant Use distinguished cmmunity-based sealant prgrams (including schl-based and schl-linked prgrams) frm individual care prgrams (private practice and public clinics). Peple treated in cmmunity prgrams are mre likely t be episdic users f primary dental care services. Furthermre, cmmunity sealant prgrams d nt prvide cntinuus care nr d they have access t a full array f caries diagnstic and treatment ptins (11). IV. Research Evidence In its systematic review f the literature, the Task Frce n Cmmunity Preventive Services (2002) fund that schl sealant prgrams are effective in reducing tth decay. The median decrease in caries n the cclusal (chewing) surfaces f psterir teeth in children was 60%. Based n this review, the Task Frce issued a strng recmmendatin that schl sealant prgrams be included as part f a cmprehensive ppulatin-based strategy t prevent r cntrl tth decay in cmmunities (3). A literature review f pit and fissure sealant in 2002 included 1,465 peer-reviewed publicatins frm 1971 t Octber 2001 and reprted that (12): It is clear that sealants are safe, effective and underused (in the United States), and Pit and fissure sealant is best applied t high-risk ppulatins by trained auxiliaries using sealant that incrprates the benefit f an intermediate bnding layer, applied under the rubber dam r with sme alternative shrt-term and effective islatin technique, and placed n tth enamel (uter tth surface) that has been cleaned and etched. An analysis f nine clinical studies with a randmized, half-muth, clinical trial design and seven studies with bservatinal study designs fund gd evidence that sealants are efficacius and effective in highcaries-risk children as lng as the sealant is retained (4). Sealants are mre effective in preventing further caries and prviding cst savings in a shrter time span if placed in children wh have high rather than lw caries risk. Anther cmparisn n the csts f sealant delivery strategies als shwed that amng high-risk ppulatins fr dental caries, less cst and reduced caries results frm placing sealants n all children f a high-risk ppulatin versus nly placing sealants fr thse children assessed t be at risk by individual screening (13). Amng lw-risk ppulatins fr dental caries, less cst results frm placing sealants nly fr children assessed t be at risk by individual screening, cmpared t the strategies f placing sealants n all children r nt prviding any sealants. V. Best Practice Criteria Fr the best practice apprach f Schl-based Dental Sealant Prgrams, the ASTDD Best Practices Cmmittee has prpsed the fllwing initial review standards fr five best practice criteria: Schl-based Dental Sealant Prgrams 6

7 1. Impact/Effectiveness: The prgram delivers t large numbers f high-risk children with susceptible permanent mlar teeth. The prgram maintains a quality assurance system that includes technical quality (the sealants placed have a high rate f retentin) and apprpriateness (the children receiving sealants are at high caries risk). 2. Efficiency: The prgram uses the least expensive persnnel permitted by state laws t screen children and deliver dental sealants with adequate training and quality assurance. 3. Demnstrated Sustainability: The prgram demnstrates sustainability by establishing a track recrd r a reasnable plan fr cvering prgram expenses. 4. Cllabratin/Integratin: Cllabrative partnerships are established t administer and sustain the prgram. 5. Objectives/Ratinale: The prgram s gals and bjectives are linked t the state and/r natinal ral health gals and bjectives. VI. State Practice Examples During the first phase f the ASTDD Best Practices Prject, states submitted descriptins f their successful practices t share their experiences and implementatin strategies. The fllwing practice examples illustrate varius elements r dimensins f the best practice apprach fr Schl-based Dental Sealant Prgrams. These reprted success stries shuld be viewed in the cntext f the state s and prgram s envirnment, infrastructure and resurces. End-users are encuraged t review the practice descriptins (click n the links f the practice names) and adapt ideas fr a better fit t their states and prgrams. A. Summary Listing f Practice Examples In FY , fur states submitted practice descriptins f their schl-based dental sealant prgrams t the ASTDD Best Practices Cmmittee. The Arizna, Illinis, New Mexic and Ohi sealant prgrams illustrate substantial elements f the mdel schl-based sealant prgram described in Sectin II. See Figure 1. Each practice name is linked t a detailed descriptin reprt. Schl-based Dental Sealant Prgrams 7

8 Figure 1. State Practice Examples f Schl-based Dental Sealant Prgrams Item Practice Name State Practice # 1 Arizna Dental Sealant Prgram AZ Illinis Dental Sealant Grant Prgram IL Schl Based Dental Sealant Prgram NM The Ohi Department f Health Dental Schl-Based Sealant Prgram OH B. Highlights f Practice Examples AZ Arizna Dental Sealant Prgram (Practice #04006) Arizna s prgram began in The schl-based sealant prgram cntracts with cunties and private prviders, delivers standards/training, and requires standardized data reprting f the cntractrs. Prgram prviders include dentists, dental hygienists and dental assistants and they use prtable dental equipment that is set up at the schls. The dentists screen and prescribe sealants and the dental hygienists apply the sealants. The prgram requires participating schls t have a minimum f 65% f the students in a free r reduced lunch prgram and targets grades 2 and 6. Fllw-up screenings f children treated are made during the next schl year and 25% f third and seventh graders are assessed fr sealant retentin. Recently, Arizna s prgram made prvisins t receive Medicaid reimbursement ($24.52 fr each sealant). In additin, the prgram is making effrts t incrprate apprpriate referrals and prvide case management assistance t families in btaining care. IL Illinis Dental Sealant Grant Prgram (Practice #16004) Illinis s prgram began in The prgram gives ver 60 grants t lcal agencies but the structure f these grants is much like that f cntracts. The prgram prvides standards and training and requires standardized data reprting f their grantees. Prgram prviders include dentists, dental hygienists and dental assistants. Prtable dental equipment is set up n-site at the schls. The dentists screen and determine the teeth t be sealed and the dental hygienists apply the sealants. Illinis ffers the prgram nly t thse children wh are n the free r reduced lunch prgram and targets grades 2 and 6. The prgram prvides fllw-up screenings during the next schl year. Illinis prgram, which reimburses n a fee-fr-service basis, nly will pay fr sealants n permanent mlars and dental examinatins (reimburses $10.50 per dental examinatin and $15 per sealant n first and secnd permanent mlars). The MCH Preventive Blck Grant funds the grants. Grantees are required t treat Medicaid children and btain Medicaid reimbursement. NM Schl Based Dental Sealant Prgram (Practice #34001) New Mexic s prgram started in Since the state has n lcal health department infrastructure, the state health department perates the prgram with its wn staff. The prgram Schl-based Dental Sealant Prgrams 8

9 has dentists, dental hygienists and dental assistants n staff. Prtable dental equipment is used. The prgram dentists screen the children and prescribe sealants. The New Mexic prgram is unique in that dental assistants are permitted t place sealants under the supervisin f a dentist r dental hygienist; therefre, bth dental hygienists and dental assistants in the New Mexic sealant prgram place sealants. The prgram requires participating schls t have a minimum is 50% f the students in a free r reduced lunch prgram. New Mexic s prgram targets 2 nd and 3 rd graders but serves children in grades 1 thrugh 6. Furthermre, the prgram ffers fllw-up screenings t check sealant retentin. OH The Ohi Department f Health Dental Schl-Based Sealant Prgram (Practice #38002) Ohi s prgram began in 1984 with a demnstratin prgram. Presently, the prgram is administered thrugh grants t apprximately 20 lcal agencies (e.g., health departments, cmmunity actin agencies and hspitals). Ohi s prgram prvides standards/training and requires standardized data reprting f their lcal agencies. The prgram has dentist-dental hygienist-dental assistant teams and uses prtable dental equipment. The prgram dentists prvide dental screenings and the dental hygienists apply the sealants. Participating schls must have a minimum f 50% f the students in a free r reduced lunch prgram and rural areas qualify fr the prgram when their schl districts have a median husehld incme f n mre than 150% f the federal pverty guideline. The prgram targets grades 2 and 6 and ffer fllw-up screening during the next schl year t all third and seventh graders. An average f apprximately fur teeth are sealed per child treated in the prgram. Ohi has reprted a cst per child receiving sealants in the range f $35-$40 cmpared t a typical private practice cst fr fur sealants f ver $120. The Ohi prgram includes Medicaid billing as a key element f its business plan fr sustainability. In additin, Ohi has undertaken effrts t fund case management pilt prjects t assist the children in the prgram t access ther needed dental care. Date f Reprt: June 16, 2003 Schl-based Dental Sealant Prgrams 9

10 References 1. Kaste LM, Selwitz RH, Oldakwski RJ, Brunelle, JA, Winn DM, Brwn LJ. Crnal caries in the primary permanent dentitin f children and adlescents 1-17 years f age: Unites States, J Dent Res 1996 Feb;75(Spec N): U.S. Department f Health and Human Services. Oral health in America: a reprt f the Surgen General. Rckville, MD: Department f Health and Human Services, Natinal Institute f Dental and Cranifacial Research, Natinal Institutes f Health, Available frm: 3. Truman BI, Gch BF, Sulemana I, et al. Reviews f evidence regarding interventins t prevent dental caries, ral and pharyngeal cancers, and sprts-related cranifacial injuries. Am J Prev Med 2002;23(suppl 1): Available frm: Review. 4. Weintraub JA. Pit and fissure sealants in high-caries-risk individuals. J Dent Edu 2001 Oct;65(10): Heller KE, Reed SG, Bruner FW, Eklund SA, Burt BA. Lngitudinal evaluatin f sealing mlars with and withut incipient dental caries in a public health prgram. J Public Health Dent 1995 Summer;55: Mertz-Fairhurst EJ, Curtis JS, Ergle JW, Rueggeberg FA, Adair SM. Ultracnservative and caristatic sealed restratins: results at year 10. J Am Dent Assc 1998; Selwitz RH, Winn DM, Kingman A, Zin GR. The prevalence f dental sealant in the US ppulatin: Findings frm NHANES III J Dent Res 1996;75(SI): Assciatin f State and Territrial Dental Directrs and Centers f Disease Cntrl and Preventin, Divisin f Oral Health. Synpses f state and territrial dental public health prgrams. Available frm: 9. Oral Health America. The Oral Health America Natinal Grading Prject Available frm: U.S. Department f Health and Human Services. Healthy Peple Washingtn, DC. January Available frm: Assciatin f State and Territrial Dental Directrs; the New Yrk State Health Department; the Ohi Department f Health; and the Schl f Public Health, University f Albany, State University f New Yrk. Wrkshp n guidelines fr sealant use: recmmendatins. J Public Health Dent 1995;55(Number 5, Special Issue): Simnsen RJ. Pit and fissure sealant: review f literature. Pediatr Dent 2002 Sep-Oct;24(5): Griffin SO, Griffin PM, Gch BF, Barker LK. Cmparing the csts f three sealant delivery strategies. J Dent Res 2002 Sep;81(9): Schl-based Dental Sealant Prgrams 10

11 ATTACHMENT A Strength f Evidence Supprting Best Practice Appraches The ASTDD Best Practices Cmmittee tk a brader view f evidence t supprt best practice appraches fr building effective state and cmmunity ral health prgrams. The Cmmittee evaluated evidence in fur categries: research, expert pinin, field lessns and theretical ratinale. Althugh all best practice appraches reprted have a strng theretical ratinale, the strength f evidence frm research, expert pinin and field lessns fall within a spectrum. On ne end f the spectrum are prmising best practice appraches, which may be supprted by little research, a beginning f agreement in expert pinin, and very few field lessns evaluating effectiveness. On the ther end f the spectrum are prven best practice appraches, nes that are supprted by strng research, extensive expert pinin frm multiple authritative surces, and slid field lessns evaluating effectiveness. Prmising Best Practice Appraches Prven Best Practice Appraches Research + Research +++ Expert Opinin + Expert Opinin +++ Field Lessns + Field Lessns +++ Theretical Ratinale +++ Theretical Ratinale +++ Research + A few studies in dental public health r ther disciplines reprting effectiveness. ++ Descriptive review f scientific literature supprting effectiveness. +++ Systematic review f scientific literature supprting effectiveness. Expert Opinin + An expert grup r general prfessinal pinin supprting the practice. ++ One authritative surce (such as a natinal rganizatin r agency) supprting the practice. +++ Multiple authritative surces (including natinal rganizatins, agencies r initiatives) supprting the practice. Field Lessns + Successes in state practices reprted withut evaluatin dcumenting effectiveness. ++ Evaluatin by a few states separately dcumenting effectiveness. +++ Cluster evaluatin f several states (grup evaluatin) dcumenting effectiveness. Theretical Ratinale +++ Only practices which are linked by strng causal reasning t the desired utcme f imprving ral health and ttal well-being f pririty ppulatins will be reprted n this website. Schl-based Dental Sealant Prgrams 11