Despite the well-documented benefits, many questions remain regarding the clinical use of sealants. This is underlined by the fact that sealant use in clinical practice is significantly lower than expected given the scientific data available. I have used sealants in my pediatric dental practice since 1972 (the Nuva Seal system and Nuva Lite) and have placed an estimated 100,000 sealants in addition to overlying sealant coverage as part of preventive resin restorations.

Over the years, I have discovered that I must continuously explore my thinking about sealants to best use this effective preventive technique in my practice.

There are three key issues surrounding the sealant dilemma that require answers from me on a continuing basis:
 

1. My core beliefs about sealants and the subsequent development of my conclusions from these beliefs. 
2. The need for a foolproof sealant diagnostic scheme.
3. Developing a clinical technique for sealant placement that is predictably successful.

Core Beliefs

After studying the literature and having conversations with my colleagues, I developed a set of beliefs for sealant use. The primary basis for my beliefs comes from a review of sealants done by Robert J. Feigal, DDS, PhD, which was published in the Journal of Pediatric Dentistry. After reading Feigal’s work and other sealant literature, I developed four core beliefs:

• Sealants are effective caries preventive agents to the extent they remain bonded to teeth.
• Sealant loss (at least partial loss) is a regular event and should be expected.
• Partial sealant loss yields a surface with the same caries rate as a non-sealed surface.
• Regular sealant resurfacing (partial replacement), when necessary, is important in long-term caries protection.

From these core beliefs, it was a natural extension to reach the following conclusions:

• Every permanent first molar will be sealed or restored as indicated. “Watching” pits and fissures makes no sense.
• Expect sealant loss and prepare parents and children for this eventuality.
• The ongoing repair of sealants is necessary to prevent caries.
• Use a rubber dam, clean and re-evaluate the pits and fissures for caries, bond before sealing, and use a flowable composite, such as UltraSeal XT Plus as the sealant material.
• Be open to changing the technique as improvements become available.
• The sealant fee must reflect the time necessary for a sealant. Take repair and maintenance into consideration.
• It is necessary to have a scheduling system for sealants and re-sealants that is efficient and economically viable.

The Crystal Air air-abrasion unit from Crystal Mark.

Foolproof Diagnostic Scheme

The second issue in my process required developing a foolproof diagnostic scheme. My dilemma was inconclusiveness regarding whether the tooth I was looking at required a sealant or a preventive resin restoration. I found that I frequently took excessive chairtime trying to decide whether the tooth was caries-free (for sealant treatment) or had a cavity that required restoration. Making an incorrect decision created an inefficient treatment plan—the sealant became a restoration or the restoration became a sealant. Parents and patients also were disappointed when they found out the planned sealant was a cavity and a restoration would be necessary. There are also unplanned and unpleasant financial implications for the parent if there is a treatment plan change to a restoration.


Determining Caries Status

What is the caries status of this tooth? The JADA March 2008 issue published a report from the ADA Council on Scientific Affairs titled “Evidence Based Clinical Recommendations for the Use of Pit-and-Fissure Sealants.” It is an excellent report and, in my opinion, is required reading for serious clinicians doing sealants. However, I disagree with the statement, “Visual examination after cleaning and drying the tooth is sufficient to detect early noncavitated lesions in pits and fissures.” This is contrary to my personal clinical experience and a simplification of the caries diagnosis (or lack of caries) related to sealants. My observation of the photos included with the ADA report is inconclusive as to whether there is caries despite the claim that they are noncavitated lesions. I have cleaned like-appearing pits and fissures using caries indicator dye (Sable Seek) and air-abrasion (the Crystal Air unit by Crystal Mark) and found no caries; I have cleaned like-appearing pits and fissures and found cavitated lesions. This is the diagnostic dilemma I face many times every day I work with patients. Is this a cavity or not? My answer is: I don’t know!

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