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ADA, AAPD leaders pen letter opposing replacement of federal sealant measure

September 03, 2019

By Mary Beth Versaci

Washington –– The American Dental Association and American Academy of Pediatric Dentistry are cautioning the Health Resources and Services Administration against replacing the Dental Sealants for Children Between 6-9 Years measure.

Leaders from both organizations sent a letter Aug. 27 to the administration in response to a request for public comment on a proposed measure titled Primary Caries Prevention Intervention as Offered by Primary Care Providers, Including Dentists, that would take the place of the sealant measure.

"We are writing to express our concerns about the proposed replacement of the Dental Sealants for Children Between 6-9 Years measure with CMS74v9," ADA President Jeffrey M. Cole, ADA Executive Director Kathleen T. O'Loughlin, AAPD President Kevin Donly and AAPD Chief Executive Officer John S. Rutkauskas said in the letter. "Research has shown that sealants are effective in preventing occlusal carious lesions in the molars of children when compared with controls without sealants."

The letter points to an evidence-based clinical practice guideline released in 2016 by the ADA and AAPD that found sealants could minimize the progression of noncavitated occlusal carious lesions and effectively prevent and arrest pit-and-fissure occlusal carious lesions of primary and permanent molars in children and adolescents compared with the nonuse of sealants or use of fluoride varnishes.

"As noted, there is in fact evidence to suggest the superiority of resin-based fissure sealants over fluoride varnishes applied to prevent decay in permanent molars," Drs. Cole, O'Loughlin, Donly and Rutkauskas said. "While both topical fluoride as well as dental sealants are important caries preventive modalities, we fail to see the agency’s rationale for removing the focus on improving sealant rates, especially given the improvement health centers have made."

As reported by 1,362 administration-funded health centers, their performance improved more than 10 percentage points between 2015 –– when the sealant measure was first adopted –– and 2018. Nearly 53% of children 6 to 9 years old who are at an elevated risk for caries received the recommended sealants. Thirty-six states also have performed better by at least 5 percentage points on the measure from 2015 to 2017.

"However, we note that a performance gap continues to exist and regret to see the agency moving away from a focus on this measure when the structures and systems have been put in place to help us sustain and continue to scale this improvement," Drs. Cole, O'Loughlin, Donly and Rutkauskas said.

The administration explained its rationale in a letter to health centers, stating the fluoride varnish measure would increase the target population from high-risk children who are 6 to 9 years old to children and adolescents as old as 20 and also include oral health preventative measures that health centers without dentists can employ.

"The application of fluoride varnish to the teeth of children reduces the risk of development of caries," the administration stated. "Increasing the use of non-dental providers (i.e., primary care providers) providing fluoride varnish to their patients can reduce the incidence of caries and promote better oral health."

However, the fluoride varnish measure would track only one application of varnish during the measurement period, contrary to evidence-based guidelines that state topical fluoride should be applied every three to six months in children at an elevated risk for caries, Drs. Cole, O'Loughlin, Donly and Rutkauskas said.

"The ADA and the AAPD encourage the HRSA to only consider metrics that are supported by strong scientific evidence and further tested for validity, feasibility, reliability and usability," they said.

The officials also said the sealant measure was developed and tested by the Dental Quality Alliance, an entity convened by the ADA that maintains the measure through a periodic review process to align it with emerging science and implementation experience.

"The use of measures that have not been adequately tested undermines confidence in measures among providers and consumers of health care," Drs. Cole, O'Loughlin, Donly and Rutkauskas said.