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. Literature suggests that sealants prevent 86% of caries after one year, 79% after two years, and 59% after three years.2,3

According to the “Workshop on Guidelines for Sealant Use: Recommendations26 published in a special issue of the Journal of Public Health Dentistry in 1995, the following principles and scientific facts should underlie the use of pit and fissure sealants in private and public programs:

  • Prevention of dental caries is better than treatment; therefore, sound, diseased teeth are more highly valued than adequately restored teeth.
  • 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.
  • Pit and fissure caries attacks begin in childhood and continue throughout adolescence and into adulthood.
  • In addition to preventing carious lesions, sealants can arrest caries progression.
  • Effective sealant use requires meticulous application techniques, particularly moisture control. Sealant retention should be checked within one year of application.

Executive summary of evidence based clinical recommendations for the use of pit-and-fissure sealants4 is a useful tool that can be applied in making evidence based decisions about sealant use. 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.

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.

In spite of high prevalence of fissure sealants there is an unequal caries experience among 6-9-year-old children by gender, ethnicity and family income level.1 To improve this situation, persons important to the promotion of dental health should try to ensure fissure 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.
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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).

Figure 2.
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Figure 3.
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Figure 4.
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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.