PURPOSE: This paper reviews key issues of sealant use and methodology and poses recommendations to inform the discussion toward a consensus statement by participants. This paper discusses key questions about sealant use in light of contemporary caries data and cost-benefit analyses. New material advancements are reviewed as well.
MATERIALS & METHODS: This paper did not have any true materials or methods. It was basically a review of information collected from previous research. The purpose of this paper is to review previous large group agreements on sealant use in light of the most contemporary literature. A goal is to uncover persistent beliefs and myths about sealants that need changing based on the newest research.
RESULTS: Pits and fissures account for 88% of caries in children while making up only 13% of total tooth surfaces. The surfaces most at risk for caries in young patients are occlusal surfaces of permanent first and second molars. The overall smooth surface caries rate has decreased significantly, the percentage of total caries attributable to pits and fissures has increased. Pits and fissures account for about 80% of all caries in young U.S. patients. Initiation of new carious lesions in pits and fissures of molars 4 years after the eruption has decreased more than 70% over 20 years. In this study in a fluoridated community, molars scored initially as the sound became carious at a rate of 13% if not sealed and at rate 8% if sealed. Molars scored initially as incipient or questionable became carious at a rate of 52% if not sealed and a rate of 11% if sealed. Over the 5 years of data collection, on average, 25 sealed molars resulted in the prevention of one occlusal restoration.
DISCUSSION: It is universally understood that caries rates have fallen dramatically for populations in industrialized nations and that education levels and socioeconomic status relate inversely with caries experience. For most contemporary clinicians in fluoride-rich areas, it would be better to underdiagnose early caries, since many incipient lesions either become inactive, remineralize or progress very slowly to cavitation. A more contemporary perspective is that sealants should be directed to those teeth judged at risk for caries, not directed to all teeth with pits and fissures. Pits and fissures have always been the earliest and most prevalent of carious areas, with these surfaces accounting for over 80% of all caries in young permanent teeth. It is clear that to gain the greatest benefit for the sealant treatment, it is imperative to determine caries risk of teeth and then to seal those that have the highest risk of caries. Careful cleaning of the enamel surface and the fissure followed by effective etching of the fissure walls will result in a successful sealant and will halt the progression of any existing incipient caries. The enameloplasty procedure itself may injure normal enamel resulting in higher caries susceptibility of that fissure in the future. There are no long-term clinical studies that show that enameloplasty is safe.
SUMMARY/COMMENTS: In retrospect, early carious lesions have been watched or sealed over for decades. Sealants are an important dental caries prevention technology, ideally used in combination with patient education, effective personal oral hygiene, fluorides and regular dental visits. As the actual caries rate on non-sealed surfaces decreases, the number of sealants placed to save or protect one surface from caries must increase. Permanent molars have been selected as the teeth most at risk for occlusal caries and thus, the teeth that most benefit from sealants, however, any teeth that are judged to be at risk can certainly benefit from sealent application. Just as important as placing the sealant is to periodically evaluate it for integrity and retention. What good is an inferior sealant at that point? Personally, I think an important question to ask is, “Is it beneficial to place sealants on an adult, let’s say over the age of 30. If this individual has been non-carious and has gone all this time without any sealent coverage, would it be of any benefit to placing a sealent after all that time had passed.?
Originally published at alfredkhallouf.com on June 1, 2016.