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 At the outset it was envisaged that consultation with the HBDS was essential for the successful completion of lot 3. A user group was convened comprising of representatives of the health boards and the department of Health & children and members of the OHSRC.

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 This group met reguarly over a three year period

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 The aim of this is to ensure that resources are used in the most efficient manner with a view to improving the health of the population These influence the decision to confine or ration treatment and/or preventive services to a specific sub-section of the population eligible for such services

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 In all such reviews the concepts of targeting and rationing were considered and both of these considerations influenced the decisions reached to a varying degree

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 Reason for classes chosen.

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) Fluorides namely prevents caries in smooth surfaces

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 Cost-effectiveness questioned due to: Some surfaces would not decay so no need to seal Some sealed surfaces included in cavity design Question of dentists being over-trained

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 Developed following publication of “shaping a Healthier Future”

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 analysis Consultation process Information gathering (Literature Review) Review of existing services Secondary 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) The collaboration between the health boards and the OHSRC in the conduct of lot 3 included the development and completion of a number of projects which were directly related to the aims and objectives of lot 3

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) Three of the projects under taken by the postgraduates were directly related to the aims and objectives of lot 3

Lot 3 Caries Risk

% of total caries experience contributed by top 20% of dmft/DMFT score Up until recently it was stated that the distribution of caries amongst children and adolescents was skewed and that 80% of caries occurred in 20% of the population. Hence targeting of the high risk group for preventive and treatment services was widely recommended. However looking at these results from the national survey this high risk strategy is unlikely to be successful because apart from primary teeth in 5 year olds, the skewed distribution does not exist. Caries Risk assessment was whereby attempts at early identification of this 20% for targeting preventive services

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 The development of an efficient method for identifying high caries risk subjects remain elusive despite intensive research nationally and internationally. The difficulty is that caries is an aetiologically complex and multi-factorial disease process and many factors can determine an individual patients caries risk

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) Percent Erupted Tooth_16 Tooth_26 Tooth_36 Tooth_46 Age range over which 95% of first permanent molars erupt is between 4.5 and 8 years approx. The corresponding age range for 2nd permanent molars is between 9.4 and 13.6 54% age 7 42% age 6 39% age 11 55% age 12

Targeting of school classes for fissure sealing

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 The main focus of this strategy is identification of children and adolescents in need of dental treatment including fissure sealing. This needs assessment strategy was developed by the Lot 3 Hb subgroup in collaboration with OHSRC and is included as an appendix in the Lot 3 report. This strategy would help both to identify children at risk of caries and to prioritise those in need of prevention and treatment services A major finding of the Lot 3 consultancy contract is that for a fissure sealant strategy to be successful, it is essential that children in almost all primary school classes and in first and second year of secondary school be regularly screened

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 There was wide variation among this group but the prevalence may be linked to the timing of the survey. It is also interesting to note that dependants of medical card holders had less fissure sealants on their teeth

% of 12-year-old children with at least one fissure sealant on their permanent teeth by disadvantage status There was less variation among the older age groups between health boards but the disparity between mc status and none is still there

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

2) A very high proportion of dental decay occurs in pits and fissures National Survey Children's Oral Health 2002

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 Meticulous application required for effective retention and Failure of sealants primarily due to operator technique

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 It is important to ensure that all dental personnel involved in dental screening be trained and calibrated to ensure a consistent approach and reduce inequalities in oral health

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 1984 All HB 8 12 15 1984 1.7 6.4 8.7 2002 1.8 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

Caries in primary teeth Wide variation between health boards in the percentage of untreated total decay experience in primary teeth Overall 83.9% of caries untreated in children of non-medical card holders. In children of medical card holders the figure is 82.4%

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