Methodology

In 2011 and 2012, Pew conducted surveys of both state dental directors and state dental boards. Additional data were gathered from the National Oral Health Surveillance System (NOHSS). States were given points for each benchmark, and grades were based on the sum of points earned for the four benchmarks. Though data for 2011 were collected, points and grades were awarded only for 2012 data. We graded states on an A to F scale:

Benchmark #1: Percentage of High-Need Schools with Sealant Programs

State dental directors were asked for the percentage of high-need schools with sealant programs. States used a variety of sources to estimate the percentage of these schools with school-based sealant programs, including regularly updated databases and staff estimates. In general, states defined high-need schools as those in which more than 50 percent of students participate in the federal Free and Reduced Lunch Program; a few states had slightly different definitions. Low-income children have been shown to have a greater risk of tooth decay.^[i] School-based sealant programs that specifically target high-need schools have been shown to be effective in reaching these children.^[ii] Respondents were asked which of the following categories accurately described their state’s status:

• programs reaching 75 percent or more of high-need schools,
• programs reaching 50 to 74 percent of high-need schools,
• programs reaching 25 to 49 percent of high-need schools,
• programs reaching less than 25 percent of high-need schools, or
• no programs.

States were given 4 points for 75 percent or higher, 3 points for 50 to 74 percent, 2 points for 25 to 49 percent, 1 point for less than 25 percent, and 0 points for no programs.

States used a variety of data sources to estimate these percentages, ranging from high-quality surveys to staff estimates; going forward, health officials need support in developing an adequate system for collecting critical dental health data.^[iii]

Benchmark #2: Rules Restricting Hygienists

State dental directors and dental regulatory boards were surveyed regarding the ability of hygienists to apply sealants without a dentist’s prior exam in schools as of July 1, 2011, and then were re-surveyed to determine regulations as of July 1, 2012. Pew staff resolved discordant responses through a review of hygienist rules and discussions with both dental directors and dental boards. If changes were made to regulations since the 2011 Pew survey, respondents were asked to place their states into one of the following four categories:

• A dentist’s exam is not required prior to a hygienist applying a sealant (EN).
• A dentist’s exam is sometimes required (e.g., certain classifications of dental hygienists, such as public health hygienists, can place sealants without a dentist’s prior exam) (ES).
• A dentist’s exam is always required (EA).
• A dentist’s exam and indirect or direct supervision are required (DS).

States were given 4 points for EN, 3 points for ES, 1 point for EA, and no points for DS. Under direct supervision, a dentist is on-site while the hygienist is practicing; the dentist both authorizes sealant placements before the hygienist performs them and checks all patients afterward. Under indirect supervision, an on-site dentist is required to authorize the hygienist’s application of sealants but does not check all patients after sealants are placed.^[iv] 

It is worth noting that in some states without a prior-exam restriction, other rules may exist that can complicate the logistics of operating school-based sealant programs.

Benchmark #3: Collecting and Submitting Data to the NOHSS

States’ submission of sealant data to the NOHSS was assessed using publicly available data from the Centers for Disease Control and Prevention (CDC).^[v] If states submitted those data, Pew assessed if CDC reported data that were too outdated (older than the 2006–2007 school year) to use for planning programs and strategies. Both the CDC and the Association of State and Territorial Dental Directors (ASTDD) advise states to provide data that are not older than five years.^[vi] 

States were given no points for never participating in NOHSS, 1 point for monitoring sealants but only having data prior to the 2006–2007 school year, and 2 points for monitoring sealants and having recent data.

Benchmark #4: Meeting Healthy People 2010 Sealant Goal

One measure reported in NOHSS is the percentage of 3rd grade children with sealants. The federal Healthy People 2010 objective for sealants is that 50 percent of children in this age range should have sealants. This objective also seeks to close any disparities in sealant rates among kids, including disparities that occur by income levels.^[vii] 

States were given 1 point if they had recent data (2006–2007 school year or newer) that showed them having over 50 percent of 3rd graders with sealants. Pew was unable to ascertain from the data reported to NOHSS the prevalence of sealants among low-income children, so is unable to give additional credit to states that may have reached this very important goal. States received 0 points if they had no recent data or no data indicating they met the Healthy People 2010 objective.

  [i] Here “affluent” is defined as a family income of two times the federal poverty line. Low-income is defined as those below the poverty line. Dye, B. A., Tan, S., Smith, V., Lewis, B. G., Barker, L. K., Thornton-Evans, G., et al. (2007). Trends in oral health status: United States, 1988-1994 and 1999-2004. Vital and Health Statistics. Series 11, Data from the National Health Survey (248), 1–92, Table 10, p. 23.

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