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Sealants: The Added Link in Prevention

Course Number: 673

Sealant Utilization Considerations

Multiple studies confirm the reduction of pit and fissure carious lesions with the placement of sealants, but sealant placement continues to be underused. Some of the same questions that were brought up when sealants were first introduced continue to be concerns even as scientific evidence supporting the use of sealants continues to grow. It is possible these considerations are responsible for the under-utilization of this proven preventive procedure. The following list includes some common questions that continue to be asked regarding the use of pit and fissure sealants:

Sealing Incipient Lesions - Do the Caries Continue to Progress?

Research findings consistently indicate the caries process is inhibited when sealants are applied to incipient lesions. These findings have been demonstrated radiographically and microscopically. A systematic review by Griffin et al., 200812 examined the effectiveness of sealants in preventing caries progression and found that the median annual percentage of non-cavitated lesions progressing was 2.6% for sealed and 12.6% for unsealed carious teeth. They concluded that sealing non-cavitated caries in permanent teeth is effective in reducing caries progression. The intact sealants provide "100% protection" in preventing caries. The percent of progression of carious lesions increase minimally over time as sealant integrity was compromised. Despite this good evidence, a recent survey on dentists' perspectives on evidence based recommendations suggested that the U.S. dentists have not adopted evidence-based clinical recommendations regarding the sealing of non-cavitated caries lesions (NCCLs).13 According to practice guidelines published by the American Dental Association in 2018, experts recommend the use of sealants plus 5% sodium fluoride varnish applied every 3-6 months or sealants alone, versus fluoride varnish only.14

Retention Rates - What if the Sealant Falls Out?

While placing sealants, steps need to be taken that enhance sealant retention such as having a very dry field for RBSs, or, instead, consider utilizing hydrophilic GICs. RBSs retention is principally the result of resin tags penetrating the microporosities that occur when enamel is etched properly and the field is dry. In general, properly placed sealants do not fall out. In a systematic review by Griffin et al., 2009, it was found that surface cleaning with toothbrush and assistance during sealant placement may result in higher retention.12 Cochrane Database of Systematic Review3evaluating caries prevention by sealants concluded, the reduction in caries ranged from up to 51% in 12 months with similar results at 48 months. If the occlusal bulk wears away or is lost, there is clinical evidence the resin tags remain and the surface is protected. The photograph in (Figure 5) shows a sealant with the tooth structure dissolved leaving only the resin tags.

Figure 5. Sealant with the tooth structure dissolved.

Loss of GICs is not associated with the risk of developing caries because small particles remain at the bottom of fissures acting as a fluoride reservoir and enhancing nearby remineralization.

Griffin et al., 2009 in a systematic review reported that teeth with fully or partially lost sealant were not at a higher risk of developing caries than were teeth that had never been sealed.12 Inability to provide a retention-check examination to all children participating in school sealant programs because of loss to follow-up should not disqualify a child from receiving sealants.12 Further, a 2014 study by Fontana et al15 suggested that occlusal surfaces without frank cavitation that are sealed with a clear sealant can be monitored with International Caries Detection and Assessment System (ICDAS), quantitative light-induced fluorescence (QLF), or DIAGNOdent, which may aid in predicting the need for sealant repair.

Will the Unsealed Etched Surface be More Susceptible to Caries?

Remineralization begins as soon as saliva coats the surface and forms an organic pellicle over the etched tooth structure; thus, the tooth surface is protected. For reference, the etching process used for sealants removes about 10 microns of enamel and polishing with pumice removes about 4 microns.

Cost Effectiveness - Do You Save Money?

For years, average cost of a one-surface amalgam restoration has remained about double the cost of a sealant. Studies suggest sealants are cost-effective, particularly in children at increased risk for tooth decay.16,17 Having auxiliaries perform this procedure can also reduce the cost. Placing sealants at the time of the recall appointment and using a risk assessment protocol to determine which surfaces to seal are also ways to reduce cost.

Removing Tooth Structure - Is it Necessary?

Using a bur to clean out pits and fissures prior to the placement of a composite resin or RBSs sealant is known as a preventive resin restoration (PRR). While some providers may continue this approach, it is no longer supported by current caries research, akin to other antiquated clinical techniques such as “extension for prevention.” Non-cavitated occlusal surfaces do not require removal of tooth structure and sealed incipient caries lesions will arrest. According to the 2015 International Caries Consensus Collaboration, representing 21 global experts in cariology, “The failure to follow new evidence is not limited to dentists who are “out of touch,” do not undertake continuing professional development, or have been practicing for many years; in some countries and some schools, new dentists are still taught to remove all infected carious tissue, and it is actually not possible to pass professional examinations without demonstrating this. The reasons underlying this failure to translate evidence into clinical practice are many and complex.”18 Air abrasion is sometimes used to clean out pit and fissures prior to placement of sealants. Many states interpret the use of air abrasion as removal of hard tooth structure and, therefore, not all auxiliaries will be allowed to place the sealant materials. Labor is a major cost in the dental office; it is more effective to use qualified auxiliaries.

Payment - Do Insurance Companies Cover this Procedure?

Medicaid coverage in all 50 states covers the placement of pit and fissure sealants. Most Health Maintenance Organization’s dental plans cover sealants as a preventative procedure. Also, many of the fee for service plans cover sealants because they have determined the use of sealants is a cost effective method of preventing higher cost restorative treatment. The Centers for Medicare and Medicaid Services (CMS) national oral health goal is to increase the rate of sealants in the Medicaid/Children’s Health Insurance Program (CHIP) population.