Why aren't dentists following sealant guidelines?

Large, multisite dental practices may be the way of the future, but practitioners at these sites may not be leading the way in following recommendations for sealing noncavitated occlusal carious lesions in children. To learn more, researchers sought to identify the barriers to guideline adoption facing dentists at a typical, large practice.

Investigators surveyed general and pediatric dentists at a large, multisite dental practice about facilitators and barriers to adopting the ADA's 2016 pit-and-fissure sealant clinical practice guideline (BMC Oral Health, February 2, 2018).

"Consistent with our hypotheses, we found that dentists were unaware of the guideline, they do not believe in the effectiveness of sealants to arrest decay, and they did not believe that applying sealants is the standard of care," lead study author Deborah E. Polk, PhD, told DrBicuspid.com.

Polk is an assistant professor of dental public health at the University of Pittsburgh School of Dental Medicine.

What's the problem?

Dental caries are common in children, with occlusal surfaces of molars the most vulnerable area. Applying sealant to these surfaces is the best way to protect them, preventing the occurrence of new caries and arresting the progression of early ones, as well as preventing the need for a restoration, the authors wrote.

Research has found that children and adolescents treated with sealants on sound occlusal surfaces or early caries in primary or permanent molars had a 76% reduction in the risk of developing new carious lesions over the next two years. Additionally, applying sealant on occlusal surfaces has been found to be more beneficial than other interventions, such as application of topical fluoride and professional dental cleanings.

Therefore, the ADA developed in 2008 and later updated in 2016 the "Evidence-based clinical practice guideline for the use of pit-and-fissure sealants," which addresses recommendations for using sealants in preventing carious lesions on the occlusal surfaces of primary and permanent teeth in children and adolescents.

"We decided to conduct the study because the ADA's pit-and-fissure sealant guideline is not widely adopted by dentists," Polk stated. "Because we expect dental practices to undergo the kind of consolidation seen in medicine, we wanted to identify facilitators and barriers facing dentists in a large, multisite dental practice."

Multisite practices are structured differently than small private practices, so barriers to implementing guidelines may be different, the authors noted.

The researchers surveyed the 110 general and pediatric dentists at a multisite U.S. dental practice using the organization's email system. Invitations to participate included a link to an anonymous web-based multiple choice survey that focused on barriers to guideline adoption in three domains: practice environment (organizational context), prevailing opinion (social context), and knowledge and attitudes (professional context).

Practice environment questions investigated financial disincentives, perception of liability, patient expectations, and organization constraints, such as workflow. Those about prevailing opinion asked about standards of practice, opinion leaders, training, awareness of the guideline, and practice policy awareness. Questions assessing knowledge and attitudes examined sense of competence, perceived need to do something, and beliefs about effective treatments.

Of the dentists contacted (63 general dentists and five pediatric dentists), 62% completed the survey. Their average year of dental school graduation was 1999.

Liability risk was the only practice environment barrier endorsed by many of the dentists (33%).

Many barriers of prevailing opinion were frequently endorsed, with many dentists underestimating the percentage of their colleagues already implementing the guideline; misunderstanding the standard of practice (59%); and being unaware of the expectations of opinion leaders (56%), including being unaware of the guideline itself (67%) and what is being taught in dental schools (58%) and also that applying sealants to noncavitated occlusal carious lesions was official practice policy.

Regarding knowledge and attitudes, many dentists indicated that they lacked knowledge about the relative efficacy of the different ways to manage noncavitated occlusal carious (50%); believed that sealants were not effective at arresting decay and that restoring a noncavitated occlusal carious lesion provides a better outcome than sealants; and said they had suboptimal skills in applying sealants (23% to 47%).

"Contrary to hypothesis, the dentists did know the difference between an early lesion that can be arrested with a sealant versus a more established lesion that must receive a restoration, and they do have the office workflow structure to support the application of sealants," Polk stated.

More work to do

The study limitations included that the reliability of the survey method was unknown and the possibility of nonresponder bias.

Future studies should address ways to implementing guidelines and test implementation strategies, according to the authors.

"This study is laying the groundwork for future studies," Polk noted.