Abstract
Objectives:
Financial viability can be a challenge in implementing school sealant programs (SSPs). We provided efficiency benchmarks for 2 measures—clinical labor time and labor cost per child—to help SSPs evaluate their performance and quantify the effect of implementation practices on these efficiency measures.
Methods:
We analyzed a convenience sample of data from 107 SSPs delivering sealants in 11 US states to 58 664 students during school years 2017-2018 through 2022-2023. We estimated measures of sealant service efficiency (SSE) per child sealed (SSEtime and SSElabor cost) and used multivariable linear regression models to identify associations between SSP practices and each SSE measure. Because of their skewed distributions, we log-transformed SSE measures. To aid interpretation, we converted resulting regression coefficients back to their original linear scales (hours and US dollars).
Results:
The median SSEtime and SSElabor cost were 0.95 hours (IQR, 0.56-1.53) and $43.25 (IQR, $23.22-$74.91). The smallest SSP size (sealing 11-60 students) as compared with the largest (sealing 390-14 589 students) was associated with an increase in SSEtime of 0.34 hours (20 minutes; β = 0.399, SE = 0.189, P = .04) and SSElabor cost of $14.45 (β = 0.431, SE = 0.200, P = .03). The use of dentists as dental operators was also significantly associated with increased SSElabor cost at an increase of $3.61 (β = 0.126, SE = 0.140, P = .02).
Conclusions:
Our findings suggest that SSP labor efficiency could increase with program size (ie, economies of scale) and by using nondentist operators when possible.
Untreated tooth decay is one of the most prevalent childhood diseases in the United States, 1 disproportionately affecting Mexican American and non-Hispanic Black children and children from low-income households. 2 Pain, infection, and resulting treatment for children with tooth decay can result in lost time at school and lower grades than among children without tooth decay.3,4 About 90% of decay in the permanent teeth of children and adolescents occurs in the molars. 5 Although dental sealants prevent about 80% of molar decay in 2 years,6,7 only 41.7% of children aged 6 to 11 years have at least 1 sealed molar. 2 Sealant prevalence is notably lower for non-Hispanic Black children (31.7%) and children living in poverty (37.8%). 2 School sealant programs (SSPs) are recommended by the Community Preventive Services Task Force based on strong evidence that they increase sealant receipt, reduce disparities in sealant receipt by income, and decrease tooth decay. 7 These programs also save costs when serving children with elevated risk for tooth decay. 8 SSPs, however, are underused. 9
The reported cost to deliver sealants to a child through SSPs varies widely, 8 which could be attributable to differences in SSP implementation practices. Although most SSPs employ licensed dental professionals (eg, dentists, dental hygienists) to go to schools where children are likely to lack access to dental care, the type of sealant material used, the number and type of dental operators, and the program size may vary.
Description of SSPs
SSPs operate in many states and locations, often focusing on schools with students who are likely to lack access to dental care (eg, high participation in free and reduced-price meal programs, rural communities). Although SSPs operate differently, they typically direct services toward children with erupted first molars (approximately aged 6 y) and second molars (approximately aged 12 y). SSPs are often funded directly by states, through government or charitable grants, or as extensions of local health departments and centers. SSPs typically obtain permission from school district administrators to operate in schools and agree on locations that will most benefit from SSP events. Programs coordinate approved dates for SSP events with school principals. Parental consent forms are distributed in advance of services being provided, and those children returning consent forms are invited to participate on event days.
On a typical event day, SSP operators arrive at the school in the morning, set up portable sealant stations, and prepare materials for daily work. Students are released from class to report to SSP operators for dental screening and sealant placement. SSPs may screen and seal children’s teeth at the same seating or, in some cases, screen children and call them back at a later event for sealant placement. SSPs may provide additional preventive services (ie, fluoride varnish, tooth cleaning). After all eligible students are attended to, SSP operators remove sealant stations and materials from the school.
Purpose of Evaluation
Two common barriers exist to implementing SSPs: inadequate reimbursement 10 and difficulty in gaining access to schools because of concerns about time taken from classroom instruction. 11 These 2 barriers could be addressed by increasing SSP labor efficiency. First, delivering sealants more quickly would decrease time out of class. Second, increasing labor efficiency could allow programs to operate at lower labor costs, which account for about two-thirds of overall SSP costs. 11 Decreased sealant delivery costs may allow SSPs to increase operational capacity within their given budget, increasing potential SSP coverage and sustainability.
The Centers for Disease Control and Prevention (CDC) Division of Oral Health has funded state oral health programs to implement SSPs since 2003. To help SSPs in CDC-funded states measure costs and efficiency with minimal data collection, the Division of Oral Health worked with state oral health sealant coordinators, SSP administrators, and economists to understand SSP implementation (eg, delivery processes), resource use, and resource costs. 12 From this effort, a web-based data collection and analysis tool, Sealant Efficiency Assessment for Locals and States (SEALS), was fielded in 2017. 13 The Division of Oral Health asked funded states to recruit local SSPs to input data into SEALS for at least 1 school year during the funding period. SSPs that used SEALS had access to a help desk and online recorded modules or live training to assist with data entry.
In this study, we used SSP data to estimate program-level labor efficiency benchmarks specific to sealant service efficiency (SSE). These benchmarks served as a reference point with which SSPs could compare themselves. We also estimated the contribution of various implementation practices to SSE measures so that SSPs could approximate efficiency improvements with adoption of these practices.
SSE Measures
SSE measures are calculated per child sealed because most programs reported only aggregate totals for children and teeth sealed, not individual child-level data.
The first SSE measure represents the program event time per child sealed. Program event time attributable to sealant delivery is equal to the total labor hours spent in a school minus any hours devoted to other services (ie, fluoride varnish, tooth cleaning). This measure includes time for equipment setup and removal, waiting between students, student screenings regardless of sealant receipt, and sealant placement. SSPs indicated that recording time for each activity separately would create a substantial data entry burden; therefore, detailed times are not collected in SEALS. We divided the program event time attributable to sealant delivery by the total number of children sealed to obtain the program event time per child sealed (SSEtime).
The second SSE measure was program labor cost per child sealed. Labor hours entered into SEALS are categorized by dental provider type. For each dental provider type, we multiplied SSEtime by the corresponding hourly compensation and summed these values across all dental provider types to obtain the total labor cost attributable to sealant delivery. We divided this total by the number of children sealed to calculate program labor cost per child sealed (SSElabor cost). For cross-year comparisons, all values for SSElabor cost were adjusted to 2022 US dollars by using the Employment Cost Index. 14
Methods
Dataset
At the beginning of a school year, SSPs enter information into SEALS regarding the following: program characteristics (eg, number of sealant stations) and logistics (eg, whether they provide other preventive services such as fluoride varnish), number of dental providers at chairside, per-student time to deliver nonsealant services (ie, fluoride varnish, tooth cleaning), and per-unit cost of resources (eg, hourly compensation for each type of dental provider). These data were collected for program evaluation under CDC cooperative agreement 5U58DP001480-05, with the intent to improve public health practice. As such, it was deemed exempt from CDC institutional review board approval. SEALS allows SSPs to select either the provided default hourly compensation rates from hourly labor costs obtained from the Bureau of Labor Statistics or program-specific rates that they manually enter. 14 For each school served, SSPs enter information on units of resources used (eg, labor hours for each dental provider type) and number of preventive services, including sealants delivered. Because of missing data for other SSP resource categories, our study focused on labor use and cost. We used data entered by SSPs into SEALS during 6 school years (2017-2018 through 2022-2023).
Study Population
The unit of observation was SSP implementation in a single year. Many SSPs provided multiple years of data, resulting in a total of 173 observations from 14 CDC-funded states, serving 61 372 students. For this study, we excluded 13 observations that delivered sealants to <10 students, which left 160 observations (86 unique SSPs) serving 61 331 students across 12 states.
Explanatory Variables
We examined the association between SSP efficiency, measured by SSElabor cost and SSEtime, and the following implementation practices hypothesized to be associated with efficiency:
SSP size, as measured by number of children sealed, by quartile: the fixed costs of setting up sealant stations may decrease per child as more children are sealed.
Having 2 dental operators (vs 1) present at sealant placement: although having 2 dental operators could reduce overall chair time, it could increase SSElabor cost with the addition of another dental operator.
Using a dentist as a dental operator: some states have dental practice acts that require dentists to perform dental screenings prior to sealant delivery and/or to perform or directly supervise sealant placement.
Using resin-based sealant material (vs glass ionomer): resin-based sealants are more technique sensitive and may require more time to place than glass ionomer material.
Using disposable instruments (vs sterilizing metal instruments between patients): the labor time and associated labor costs of autoclaving reusable instruments could be higher than replacing used disposable instruments.
Statistical Analyses
We examined the distribution of SSE measures and identified outlier values that were likely data errors. For this analysis, we trimmed 10% of the 160 observations based on SSEtime: specifically, the 8 lowest values (0.07-0.16 hours or 4-10 minutes) and the 8 highest values (5.70-46.32 hours; data not shown). The trimmed distribution of SSEtime resulted in 144 observations (76 unique SSPs) serving 58 664 students across 12 states.
We used multivariate linear regressions to analyze SSP practices that may be associated with SSEtime and SSElabor cost. The models included observations with complete data for all explanatory variables (n = 135 observations serving 53 997 students across 11 states). We used separate regression models for the 2 SSE measures. The explanatory variables in both regressions included our 5 implementation practices hypothesized to be associated with efficiency. We also included the state where the SSP was located and the school year of sealant delivery as independent variables in the model. Because some SSPs reported multiple years of data, we treated the SSP as a unit with repeated measures to account for the lack of independence between these observations.
Because of a positive skew in the dependent variable for each regression, we mathematically transformed SSEtime and SSElabor cost to logarithmic scale. Regression parameters were significant at P < .05. After completing the analysis, we reversed the log transformation and returned the coefficients (ß) back to the linear scale by taking the inverse of the natural log (e^ß) to make interpreting the findings more understandable.
Results
Among trimmed observations (n = 144; data not shown), the mean (SD) and median (IQR) for SSEtime were, respectively, 1.20 (0.94) hours and 0.95 (0.56-1.53) hours, and the corresponding values for SSElabor cost were $58.05 ($52.17) and $43.29 ($23.22-$74.91). Among the subset of observations with complete data for all explanatory variables (n = 135; Tables 1 and 2), which were subsequently used in regression analyses, SSE measures were similar. The mean (SD) and median (IQR) for SSEtime were 1.21 (0.95) hours and 0.95 (0.56-1.55) hours and, for SSElabor cost, $59.38 ($53.38) and $43.25 ($23.19-$81.25).
Summary statistics of 135 observations of SSPs that reported delivering sealants to schoolchildren to the SEALS database for school years 2017-2018 through 2022-2023 in 11 US states
Abbreviations: SEALS, Sealant Efficiency Assessment for Locals and States; SSP, school sealant program.
Disposable instruments are discarded after use on 1 patient. Reusable instruments are disinfected and sterilized between patients and used again.
Commonly referred to as 4-handed dentistry and may include the following combinations of dental operators working together on the same patient: dentist and dental assistant, dentist and dental hygienist, dental hygienist and dental assistant, or 2 dental hygienists.
Cross-tabulation of “used 2 dental operators” with “used a dentist as a dental operator” showed that 55 cases (40.7%) used neither a dentist nor 2 dental operators, 29 cases (21.5%) used 2 dental operators but not a dentist, 14 cases (10.4%) used a dentist alone, and 37 cases (27.4%) used a dentist with another dental operator.
Refers to whether the SSP used a dentist as a dental operator for screening and treating children.
School year in which the SSP delivered services.
State in which the SSP delivered services.
Summary statistics, by school year, of 135 observations of SSPs that reported delivering sealants to schoolchildren to the SEALS database for school years 2017-2018 through 2022-2023 in 11 US states
Abbreviations: SEALS, Sealant Efficiency Assessment for Locals and States; SSE, sealant service efficiency; SSP, school sealant program.
Mean (SD) varied across SSPs (each SSP’s ratio of total teeth sealed to total children sealed), not across individual children, because child-level data were not available for many programs.
Disposable instruments are discarded after use on 1 patient. Reusable instruments are disinfected and sterilized between patients and used again.
Commonly referred to as 4-handed dentistry and may include the following combinations of dental operators working together on the same patient: dentist and dental assistant, dentist and dental hygienist, dental hygienist and dental assistant, or 2 dental hygienists.
Cross-tabulation of “used 2 dental operators” with “used a dentist as a dental operator” showed that 55 cases (40.7%) used neither a dentist nor 2 dental operators, 29 cases (21.5%) used 2 dental operators but not a dentist, 14 cases (10.4%) used a dentist alone, and 37 cases (27.4%) used a dentist with another dental operator.
Refers to whether the SSP used a dentist as a dental operator for screening and treating children.
Represents the total number of labor hours spent in a school minus any hours devoted to other services (ie, fluoride varnish and tooth cleaning). It includes time for equipment setup and removal, waiting between students, screening, and sealant placement. This total is divided by the total number of children sealed.
Derived by multiplying dental provider-specific SSE time per child sealed by the corresponding hourly compensation and summing across all dental provider types. This total is then divided by the number of children sealed. All values are converted to 2022 US dollars via the Employment Cost Index. 14
Defined size quartiles, based on number of children sealed, were 11 to 60 children for quartile 1, 64 to 154 children for quartile 2, 156 to 382 children for quartile 3, and 390 to 14 589 children for quartile 4 (Table 1). Most programs used resin-based sealants (88.9%). About half of the observations (n = 66; 48.9%) used 2 dental operators, which included a dentist in 37 observations (27%). A dentist was a dental operator in approximately one-third of all observations (n = 51; 37.8%), including 14 observations (10.4%) with a dentist as the sole operator. Fewer than half (43.7%) of observations used disposable instruments. We found a decreasing trend in SSP size from 2017-2018 to 2020-2021 as measured by the number of schools served and the mean number of students receiving sealants per school (Table 2). We also found an increase in the use of disposable instruments and a decrease in the use of resin-based sealants, with programs shifting to glass ionomer materials.
Multivariable regression results (Table 3) were converted to hours and US dollars (Table 4). We found a significant association between increased SSEtime and the smallest program size quartile (β = 0.399, SE = 0.189, P = .04). An SSP of quartile 1 had an increase in SSEtime of 0.34 hours (20 minutes) per child sealed as compared with an SSP of quartile 4. We also found an association between SSElabor cost and SSP size (β = 0.431, SE = 0.200, P = .03). An SSP of quartile 1 had an increase of $14.45 per child sealed as compared with an SSP of quartile 4. The use of a dentist as a dental operator was also significantly associated with increased SSElabor cost (β = 0.126, SE = 0.140, P = .02). An SSP that used a dentist as a dental operator had a $3.61 increase in SSElabor cost as compared with SSPs that did not use a dentist. The combined effect of using a dentist as a dental operator in an SSP of quartile 1, as compared with quartile 4 without a dentist as a dental operator, led to an increase in SSElabor cost of $20.00 per child sealed.
Multivariate linear regression of SSP implementation practices results on SSE measures for (1) log of SSE time per child sealed a and (2) log of SSE labor cost per child sealed b among 135 observations of SSPs that reported delivering sealants to schoolchildren to the SEALS database for school years 2017-2018 through 2022-2023 in 11 US states
Abbreviations: SEALS, Sealant Efficiency Assessment for Locals and States; SSE, sealant service efficiency; SSP, school sealant program.
Represents the total labor hours spent in a school minus any hours devoted to other services (ie, fluoride varnish and tooth cleaning). It includes time for equipment setup and removal, waiting between students, screening, and sealant placement. This total is divided by the total number of children sealed.
Derived by multiplying dental provider-specific SSE time per child sealed by the corresponding hourly compensation and summing across all dental provider types. This total is then divided by the number of children sealed. All values are converted to 2022 US dollars via the Employment Cost Index. 14
P values are from 2-sided Wald tests for the null hypothesis that β = 0; P < .05 considered significant.
Disposable instruments are discarded after use on 1 patient. Reusable instruments are disinfected and sterilized between patients and used again.
Commonly referred to as 4-handed dentistry and may include the following combinations of dental operators working together on the same patient: dentist and dental assistant, dentist and dental hygienist, dental hygienist and dental assistant, or 2 dental hygienists.
Cross-tabulation of “used 2 dental operators” with “used a dentist as a dental operator” showed that 55 cases (40.7%) used neither a dentist nor 2 dental operators, 29 cases (21.5%) used 2 dental operators but not a dentist, 14 cases (10.4%) used a dentist alone, and 37 cases (27.4%) used a dentist with another dental operator.
Refers to whether the SSP used a dentist as a dental operator for screening and treating children.
School year in which the SSP delivered services.
State in which the SSP delivered services.
Illustration of marginal effects of significant SSP implementation practices on SSE measures as compared with reference implementation practices among 135 observations of SSPs that reported delivering sealants to schoolchildren to the SEALS database for school years 2017-2018 through 2022-2023 in 11 US states
Abbreviations: SEALS, Sealant Efficiency Assessment for Locals and States; SSE, sealant service efficiency; SSP, school sealant program.
Model reference settings were as follows: an SSP size of quartile 4, use of 1 dental operator, no use of a dentist as a dental operator, no use of resin-based material, and no use of disposable instruments. Values for reference settings were 0.71 hours for SSE time per child sealed and $26.81 for SSE labor cost per child sealed.
Represents the total labor hours spent in a school minus any hours devoted to other services (ie, fluoride varnish and tooth cleaning). It includes time for equipment setup and removal, waiting between students, screening, and sealant placement. This total is divided by the total number of children sealed.
Derived by multiplying dental provider-specific SSE time per child sealed by the corresponding hourly compensation and summing across all dental provider types. This total is then divided by the number of children sealed. All values are converted to 2022 US dollars via the Employment Cost Index. 14
We also found significant associations between increased SSEtime and the school years for 2019-2020 (β = 0.543, SE = 0.242, P = .03) and 2021-2022 (β = 0.521, SE = 0.238, P = .03). Five of the 11 states also had significant associations with decreased SSEtime (Table 3). As with SSEtime, we found significant associations with increased SSElabor cost and the school years for 2019-2020 (β = 0.687, SE = 0.345, P = .047) and 2021-2022 (β = 0.803, SE = 0.352, P = .02) and decreased SSElabor cost in 6 of the 11 states, 5 of which showed associations with decreased SSEtime, as well as an additional state that may have had decreased costs not attributable to its labor time.
Lessons Learned
Our analysis of 144 SSPs that delivered sealants to 58 664 students found a median SSEtime of 0.95 hours (57 minutes), with wide variation across SSPs. Half of the observations were 0.56 hours (34 minutes) to 1.53 hours (92 minutes). SSEtime encompasses all activities at the school beyond dental chair time: setting up and taking down equipment, disinfecting surfaces, preparing materials, changing personal protective equipment, waiting for students, and conducting other support tasks. One study of SSPs in 7 states estimated SSP chair times per student with 2-handed delivery to range from 0.28 to 0.57 hours (17-34 minutes). 15
By school year, the trend in decreasing SSP size from school years 2017-2018 to 2020-2021 may have been largely due to the presence of 1 large program (n = 14 589 students) in 2017-2018 that accounted for 85% of all children sealed. Excluding that SSP would have resulted in a mean number of 162.7 children sealed. Two notable trends during the study period—an increase in the use of disposable instruments and a decrease in the use of resin-based sealants—could have been related to the COVID-19 pandemic.
The median (IQR) SSElabor cost was $43.29 ($23.22-$74.91). This cost converted to 2024 US dollars is $46.82, similar to that reported in a Community Preventive Services Task Force systematic review of economic evaluations. 12 The systematic review further found that labor cost accounted for two-thirds of total resource costs, suggesting that for our study population, the median total cost per child would be $64.94, or $16.23 per tooth sealed. This value is lower than the 2024 median fee of $66.96 per tooth for sealants charged in dental offices. 16 An analysis of data collected in 2013-2014 from SSPs in 14 states funded by CDC (7 of which were included in our study) estimated that averted treatment costs during 4 years attributable to 1-time sealant placement on 4 molars would be $97.32 when converted to 2024 US dollars. 17 Although median fees and averted treatment costs are not directly comparable, the dollar figures suggest that SSPs could offer substantial cost savings.
Factors affecting SSP efficiency stem from self-determined and environmental factors. Self-determined factors include program-specific choices related to delivery logistics, such as the use of disposable instruments, preferred sealant material (ie, type and manufacturer), and use of multiple dental operators. Environmental factors are external to the SSP and dictate programmatic choices, such as state practice laws requiring the use of a supervising dentist. We were surprised to find that the only practices associated with efficiency were size (ie, SSPs serving ≤60 students took 0.34 hours [20 minutes] longer and spent $14.45 more per student than larger SSPs) and having a dentist as a dental provider (ie, spent $3.61 more per student than not having a dentist as a dental provider). How much control SSPs have over either of these practices is not clear. Size may also be an external factor. The efficiency of larger SSPs may be due to their ability to spread their fixed time (eg, time taken to set up equipment) across more students. We were also surprised at the extent to which efficiency varied by state. The state indicator variable may have captured information about state practice acts and factors affecting SSP size, such as policies affecting the ability of SSPs to gain access to schools.
SSP sustainability will likely improve as SSP resource costs decrease, increasing remaining margins from sealant reimbursement fees. SSElabor cost and SSEtime are validated efficiency metrics calculated and reported in SEALS. 13 SSPs can use our findings to gauge their efficiency relative to other programs and assess how program size and using a dentist as a dental provider contribute to efficiency.
Strengths and Limitations
A strength of our study was that we analyzed a trimmed, large sample that included 144 data observations from 76 unique SSPs that operated in 12 states and delivered sealants to 58 664 students. This study also had several limitations. First, we used a convenience sample that could have resulted in reporting bias (eg, participating SSPs may be systematically different from nonparticipating SSPs). Second, our study had data quality issues. Incomplete or likely erroneous data entry necessitated trimming 10% of the sample to adjust for outlier values. Third, because SEALS was designed to minimize the burden of data entry, the SSEtime measure lacked specificity to identify sources of excess school time (eg, setup time, waiting time). Finally, because our analysis focused on program time and costs associated only with labor at a school, our findings do not include additional time and costs associated with supplies, equipment, and travel.
Conclusion
SSPs perform an important function by providing access to an equitable, proven, and cost-effective intervention to prevent tooth decay among children at elevated risk of decay who are otherwise unlikely to receive sealants. 9 Our findings suggest that the resource costs to deliver sealants in school settings are lower than those incurred in clinical settings and that SSPs could generate substantial cost savings during a 4-year period. Furthermore, our findings suggest that SSP efficiency could increase by maximizing the ratio of number of students sealed to the time spent per school visit and from using nondentist dental operators when possible.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
ORCID iDs
Disclaimer
The opinions expressed in this article do not reflect the opinions of the US Department of Health and Human Services, the US Public Health Service, or the Centers for Disease Control and Prevention.