Rationale and Patient Selection
Epidemiological investigations confirm that although occlusal surfaces make up 12% of the tooth surfaces in the mouth; approximately 90% of caries in permanent teeth occurs in the pit and fissures. Further, caries in pit and fissures increase dramatically in permanent teeth between the ages of 11 and 19.1 The deep developmental pits and fissures on the occlusal surfaces predispose them to carious lesions. Unlike smooth surfaces, occlusal surfaces receive little protection from fluoridated water and topical fluoride application. Pit and fissure sealants act as a physical barrier between the occlusal fissures and the oral environment, preventing the food debris and ingress of bacteria. According to a Cochrane systematic review conducted in 2017, pit and fissure sealants reduced caries between 11 and 51% compared to no sealant when measured after 24 months. Similar outcomes were found at specific points up to 48 months.3 A systematic review conducted by Wright et al (2016) reported up to 80% reduction after 2 years.4 Numerous studies4,5 have been conducted citing success rates and clinical protocols for sealant use. Many cite similar principles and scientific theories that underlie the use of pit and fissure sealants in private and public programs including the following:
Dental caries on occlusal surfaces of posterior teeth among children and adolescents that may continue into adulthood is considered a worldwide problem.
Pit and fissure sealants prevent the growth of bacteria promoting occlusal caries formation and can arrest caries progression.
For equivalent outcomes, the least invasive approach, using the simplest intervention for managing dental caries, is preferred.
Minimizing the cost of preventing or controlling pit and fissure caries is desirable.
Strategies for sealant use (e.g., patient selection, clinical decision making) may differ between individual care and community programs.
Sealants have been demonstrated to be a safe and effective long-term method to prevent pit and fissure caries.
Effective sealant use requires meticulous application techniques, particularly moisture control with some materials. Sealant retention should be checked within one year of application.
Long term effects of sealant placement is often dependent upon parental motivation and the presence of a dental home for the patient.
Systematic reviews of evidence based clinical recommendations for the use of pit-and-fissure sealants as a useful resource in making evidence based decisions about sealant use. 4 These recommendations are not a standard of care, but should be integrated with the practitioner’s professional judgment and the individual patient’s needs and preferences.3
Guidelines for patient use in private practice differs somewhat from guidelines used in community sealant programs. Those seeking treatment in private practice settings are more likely to have continuous care, comprehensive diagnoses, and treatment options. People treated in community sealant programs are more likely to be episodic users of primary dental care services.
Risk assessment techniques for dental caries are useful in determining which patients would most likely benefit from the protection provided by the sealant. Tooth morphology, caries history, family history, home care, history of dental care, and eruption schedule (age) all play a role in selecting this procedure for a patient. Radiographs should be used to determine the extent of any incipient decay.
In spite of the high prevalence of preventive dentistry therapies, there is an unequal caries experience (treated and untreated) among 2-19-year-old children by ethnicity and family income level, with Hispanic children and those from lower income level families having the highest rates.1 To improve this situation, dental health professionals should promote proper oral health practices and encourage sealant application to permanent teeth as early as possible, especially in those children who have had caries in their primary dentition.
Figure 1. Normal first mandibular molar.
As noted above, tooth morphology plays a role in selecting specific teeth for pit and fissure sealants. The photograph of a normal first mandibular molar shows the natural occlusal morphology that tends to make cleaning difficult and creates areas for food impaction (Figure 1). It also illustrates a less than ideal situation for diagnosis of incipient lesions. The following photographs, which show the anatomy of the tooth surface in detail, further illustrates the need to seal these types of fissures (Figures 2-4).
It has been well-documented the tooth surface is constantly undergoing a remineralization and demineralization process. This makes the decision to cut into the tooth versus a non-invasive procedure a difficult one at best.