Methods. The authors mailed a 20-question survey to American Academy of Pediatric Dentistry members from six states, who represented one-third (1,210) of the membership, as well as to all 52 pediatric dentistry departments in U.S. dental schools. The authors examined selection criteria, placement techniques, evaluation methodologies, and the one- and three-year estimated success and reapplication rates of sealant placement.

Results. The response rates were 70 percent for practitioners and 90 percent for dental schools. Approximately 80 percent of respondents said they sealed caries-free and questionable carious surfaces. Only 20 percent of the respondents said they sealed incipient carious surfaces; none said they would seal overt caries. Surface preparation was used always or sometimes by 87 percent of the respondents. The estimated one-and three-year sealant retention rates were 89 percent and 78 percent, respectively, for practitioners and 83 percent and 71 percent, respectively, for dental schools.

Conclusions. The survey demonstrated wide variations in selection criteria, placement techniques and evaluation methodologies, yet showed remarkable similarities between practitioners and dental schools. The reported retention rates were consistent with those reported in the literature.

Practice Implications. The survey results suggested that pediatric dentists were searching for evidence-based selection criteria and a technique protocol for sealant placement that improved clinical success. The wide technique variations reported were likely a result of training diversity, diagnostic uncertainty, technique and material sensitivity, and an attempt to improve the success rate.

The surveys implied that sealant placement was viewed by pediatric dentists as a valuable and frequently provided patient service.

We conducted a survey of pediatric dentists to determine the variations and patterns of sealant usage among private practitioners, or PP, and pediatric dentistry departments in U.S. dental schools, or DS. We used the survey to examine patient and tooth selection criteria, placement techniques, evaluation methodologies, and the success and reapplication rates at one and three years.

	METHODS

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Four pediatric dental department chairs knowledgeable in sealant protocols, current research findings and survey instrument design field-tested a prototype survey. After we incorporated their suggested revisions, we finalized a 20-question survey containing 16 closed-ended and four open-ended questions with a comment section for feedback.

We mailed the survey to 1,210 members of the American Academy of Pediatric Dentistry, or AAPD, who practiced in California, Colorado, Florida, Massachusetts, Michigan and Texas. We chose this sample to obtain a representative geographic snapshot of approximately one-third of the AAPD members.

We also surveyed all 52 U.S. DS pediatric dentistry departments and gave instructions that the survey be completed by the faculty person most responsible for sealant placement instruction in the undergraduate curriculum. We asked this person to answer the survey based on the accepted teaching consensus of the department and not simply his or her own practice philosophy.

We sent a second mailing to all nonrespondents. We used descriptive statistics (percentage response) to analyze and compare the results.

	RESULTS

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Usable surveys were returned by 848 of 1,210 (70 percent) of the PP and 47 of 52 (90 percent) of DS departments surveyed. The respondents were instructed to provide any comments on the back of the returned surveys. Many did so, clarifying the techniques they used or detailing their sealant experiences and philosophies.

Table 1 shows the percentage response distributed between PP and DS settings for three patient selection criteria (caries risk, recare potential and behavior) and five tooth selection criteria (tooth type, eruption status, posteruption age, surface caries status and caries evaluation technique). Overall, we found minor differences in the percentage distribution of the responses between PP and DS. The majority of respondents selected cooperative patient behavior and completely erupted permanent teeth as necessary selection criteria for sealant placement. Opposing criteria were listed under these categories in the survey; however, their selection indicated that the respondent did not use or consider it of value in selecting the patient or tooth for sealant placement.

Table 2 shows distribution of selected sealant placement techniques for antisialagogue use, isolation, and surface cleansing and preparation. Few respondents prescribed antisialagogues, although this practice was slightly more common in PP settings. When asked about their isolation method of choice in a quadrant requiring only a sealant, respondents said they preferred a cotton roll, The Dri-Angle (Dental Health Products Inc., Youngstown, N.Y.) or both over the rubber dam. Although 11 percent of PP claimed not to cleanse the surface, 18 percent selected air abrasion as their preferred method of preparing the surface. The use of air-abrasion technology in PP settings occurred at a much greater frequency than it did in DS settings. Although 87 percent of respondents performed surface preparations, we do not know if they did so to prepare the tooth surface, to explore for occult caries or both. A variety of burs was used, usually with a high-speed handpiece.

View larger version (45K): [in this window] [in a new window]   Figure 1. Acid-etching times reported by practitioners and dental schools for primary teeth, mean 29 seconds.

View larger version (47K): [in this window] [in a new window]   Figure 2. Acid-etching times reported by practitioners and dental schools for permanent teeth, mean 26 seconds.

View larger version (42K): [in this window] [in a new window]   Figure 3. Rinsing times reported by practitioners and dental schools, mean 14 seconds.

View larger version (39K): [in this window] [in a new window]   Figure 4. Drying times reported by practitioners and dental schools, mean 11 seconds.

There was about an even split between choosing to assess the sealant immediately with either a gentle or forceful explorer. Less than one-half of the respondents checked the occlusion after sealant placement.

All respondents recommended that sealants be reevaluated on a six-month basis. There was disagreement as to when and if sealants should be evaluated radiographically, as only 54 percent of respondents said they used radiographs to assess sealant effectiveness. The most common interval for radiographic assessment of sealant placement was every 12 months.

Table 4 (page 1448) demonstrates the estimated one- and three-year mean sealant retention rate, reapplication rates and failure rate due to same-surface caries, as well as the fee policies for failed sealants. With declining sealant retention rates over time, there was a corresponding increase in sealant reapplication on sound surfaces and restoration placement on carious surfaces. At three years, more than 90 percent of the sealants reportedly were successful (although approximately one-fifth—6 percent PP and 21 percent DS—required reapplication) and about 7 percent failed to prevent caries formation. Thirty-seven percent of PP and 49 percent of DS said they never charged a reapplication fee. The decision to charge a reapplication fee often was based on the sealant’s life span in years. Therefore, reapplication fee policies implied that it was common practice to have a warranty period or lifetime guarantee given with sealant placement, occasionally linked with the patient’s compliance with follow-up evaluation. The policy to charge restoration fees for sealant surfaces that became carious displayed different pattern characteristics between PP and DS. Private practice policies revealed greater leniency, higher expectations for successful outcomes or both.

	DISCUSSION

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Patient selection criteria. The majority of PP and DS reported that they placed sealants regardless of the child’s caries risk, especially when permanent molars were considered. This was the same finding as that of Clark and Berkowitz,¹⁰ who surveyed more than 6,000 Canadian children and failed to identify meaningful predictors of sealant use. In contrast, public health studies and workshops have developed specific recommendations for sealing either incipient caries¹¹ or teeth at risk of developing caries in programs targeted to low-income children with limited or no access to routine preventive dental care.^12–16 These guidelines were demonstrated to be valid in a New York State school-based program¹⁷ and have been published by the American Dental Association.¹⁸ In spite of these studies, 80 percent of respondents to our survey chose not to seal incipient caries.

Almost one-fifth of the respondents to our study (23 percent of PP and 19 percent of DS) did not consider the eruption status of a tooth in their selection criteria. Dennison and colleagues¹⁹ sealed 100 molars and found that teeth in which the operculum covered the distal marginal ridge at the time of sealing had twice the reapplication rate as teeth in which the entire colossal surface was exposed. Seventy-seven percent of PP and 81 percent of DS reported that they chose to seal only teeth that were completely erupted. A consensus workshop suggested that the posteruptive age of a permanent tooth should not be the major factor in placing a sealant, as caries can initiate after childhood.¹⁵ The workshop instead recommended basing the decision on the patient’s overall caries risk—his or her caries history, previous dental care, medications taken, pit and fissure morphology, personal oral health habits, and family and medical histories. Forty-four percent of our PP respondents and 40 percent of our DS respondents reported that they would seal only teeth that had been erupted less than three years. One might speculate that the PP and DS in our survey placed sealants based on their own experiences and not on recommended criteria.

When the survey asked respondents about how the potential for follow-up influenced their decisions to place sealants, most of the PP and DS indicated this was not an important factor. We thought this was an interesting finding, since the sealant literature clearly demonstrated that regular evaluation is mandatory for long-term sealant retention and caries prevention.^20–26

Patient behavior influenced 62 percent of the respondents’ decisions to place a sealant. Musherure and colleagues²⁷ listed the causes of sealant failure, from most common to least common: poor patient behavior, saliva control, early eruption stage and poor enamel condition. The survey supported pediatric dentists’ views of the importance of patient cooperation, since pediatric dentists often see patients with behavior challenges.

Tooth selection criteria. The teeth selected to be sealed most frequently were permanent molars, followed by premolars and then primary molars. This order may mirror the incidence of occlusal caries experienced by the respondents. The less-frequent selection of primary molars as candidates for sealant placement may be related to perceived caries risk, patient cooperation, the susceptibility of the proximal surfaces to caries, third-party reimbursement policies or a combination of factors. Studies on sealant retention for specific teeth report that premolars have the highest sealant retention and second molars show the lowest retention rates.^28–30 Examining sealant success between permanent first and second molars would be an interesting subject for future research.

The evaluation of occlusal surfaces has been addressed in many studies because of the difficulty in accurately determining the presence and extent of caries.^31–38 In an in vitro study, Penning and colleagues³⁵ found that 76 percent of the carious lesions were not discovered by probing; in another in vitro study, Lussi³³ concluded that the use of an explorer did not improve the validity of a fissure caries diagnosis. Radiographic evaluation was considered essential by Weerheijm³¹ and Miles³⁴ in making a determination of occlusal caries. Electrical conductance was found to be a good predictor of caries in three studies^32,36,37 and superior to transillumination used by Fennis-Ie and colleagues.³⁷ The respondents’ routine use of an explorer followed by an enameloplasty to diagnose caries may be related to convenience and confirmation of what appears visually to be carious.

All of the respondents said they sealed caries-free teeth, and 48 percent of the PP and 57 percent of the DS said they sealed over questionable and incipient caries. The 1998 AAPD’s Guidelines for Pediatric Restorative Dentistry state, "Sealants are indicated for noncarious primary or permanent molars and premolars with deep pits and fissures."³⁹ This guideline was in deference to a number of clinical trials that showed that as long as the sealant remained intact, caries left underneath were arrested.^40–43 One of the most frequent concerns voiced in the survey’s comments section was fear of placing a sealant over caries. These practitioners used an enameloplasty technique to explore the fissure and remarked that they frequently discovered unexpected dentinal caries that could not be seen radiographically or clinically.

Placement technique. Since a prior investigation reported that moisture contamination was the most frequently cited reason for sealant failure,⁴⁴ practitioners may need to consider pharmacologically reducing salivary flow in children with isolation challenges. The isolation method most commonly reported was the use of cotton roll and The Dri-Angle with a saliva ejector. One-third of the respondents said they placed a rubber dam even when sealant placement was the only procedure being performed. Numerous studies have shown that sealant retention rates are comparable when performed using a rubber dam or cotton roll isolation.^21,45–48 The variety of cleansing methods used by PP and DS have been shown to result in similar sealant retention rates in several different clinical trials.^49–52

Surface preparation. We found that using an enameloplasty to prepare a tooth before sealant placement was controversial, because some professionals would prefer to use the term "preventive resin restoration" when the surface has been prepared using a bur or air abrasion. Nonetheless, 17 percent of PP said they always performed an enameloplasty, and 70 percent said they sometimes did. A 1995 survey of the northern members of the California Society of Pediatric Dentists⁵³ found that 76 percent of the members sometimes used an enameloplasty and 37 percent always did. The proponents of surface preparation stated that it increased their success rate, allowed them to ascertain whether clinical caries was present and enhanced their confidence in the marginal integrity of the sealant.

The respondents to our survey reported a wide range of acid-etching, drying and rinsing times. Clinical and laboratory research supports a 15-second acid-etching time, a 10-second rinse time and a five-second drying time as sufficient to reduce salivary contamination and achieve optimal sealant retention.^2,54

Sealant materials. The most common types of sealant materials our respondents reported placing were opaque and fluoride-releasing. Fluoride-releasing sealants have been shown to be as retentive as nonfluoridated sealants.^55,56 Although their popularity was based on the assumed caries-preventive effect of the released fluoride, this protection has not been proven in clinical trials to date. The reported low use of a dentin-bonding agent under a sealant was not expected, as research has shown that it increased the bond strength and decreased microleakage in the presence of moisture contamination.^57–63 It may be that the additional step and the increased cost had dissuaded respondents from accepting this innovative approach or that they chose to place sealants only when they were confident that moisture was controlled.

Reported success rates. The estimated success rates at one and three years were reported to be higher for the PP than for the DS. This may be due to the inexperience of dental students, the more infrequent follow-up of DS patients and students working alone. Still, a one-year success rate of 89 percent for PP was relatively low, considering the controlled environment. When we examined the literature as a whole, sealant loss averaged 5 to 10 percent per year.^64–66 Since both groups of respondents estimated sealant loss rate near the upper end of the reported range cited in the literature, they may be using strict criteria to judge a failure. In addition, the survey did not ask them to discriminate between partial and complete sealant loss. Three-year success rates of 78 percent and 71 percent for PP and DS, respectively, were consistent with other studies, as were the reapplication rates. The need for sealant reapplication varied in clinical studies from 6 percent after one year⁶⁷ to 10 percent after two years⁶⁸ to 35 percent after 4.5 years.²² It appeared that the decision to reapply a sealant was based on the respondent’s clinical judgment, as there are no published criteria for sealant reapplication to help guide the operator.⁶⁹

In the present survey, the estimated caries rate was lower than that cited in the literature and was likely a reflection of the higher reapplication rate and the compliance rate for regular six-month evaluations. The caries rate for sealed molars was reported to be 6 percent after 10 years by Wendt²⁰ and 7 percent after five years by Chestnutt and colleagues.²⁶ Gale and colleagues²³ reported 14 percent of sealed permanent first molars sealed in DS clinics were carious after 4.5 years.

An interesting finding was that 37 percent and 49 percent of the PP and DS, respectively, reported never charging a fee for sealant reapplication. With such a large percentage never charging a replacement fee, it was no wonder that many practitioners questioned their cost-effectiveness. Given the overwhelming data that sealants required regular maintenance and that most insurance companies only paid for reapplication every three to five years, clinicians must feel a sense of obligation to guarantee a product they believe will require continued care.

The written comments provided by many of the respondents were lengthy, detailed and passionate. The most frequently cited points were

– the sealant failure rate experienced was unacceptable;

– many clinicians sealed only caries-free teeth;

– many were frustrated that caries detection was so difficult;

– complete tooth eruption was critical for success;

– enameloplasty was seen as the key to successful sealant retention;

– chewing hard foods and ice contributed to sealant failure (this last point was not mentioned in any of the literature reviewed and warrants further study).

Our survey design had an inherent shortcoming in that it requested the respondent to answer in general terms and estimations rather than using quantitative data from patient records. There was, therefore, the potential for the reported responses to be a misrepresentation of the actual diversity in sealant practices among pediatric dentists. The survey also was limited to pediatric dentists in six states and may not be representative of all pediatric dentists.

	CONCLUSIONS

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The wide variations in sealant use and placement techniques reported in this survey implied that there was no apparent consensus among PP and DS as to appropriate patient and tooth selection criteria and a standard sealant placement technique. The lack of standardized selection criteria and placement technique for sealants was unexpected considering the 30-year history of their clinical use, their high placement rate among pediatric dentists and their relatively simple application instructions. This finding likely was a reflection of difficulties imposed by diagnostic uncertainty, technique-sensitive procedure and material, reaction to unsatisfactory outcomes and diversity in training. Even though the reported practice patterns for sealant placement demonstrated differences in patient and tooth selection criteria, placement techniques and evaluation methodologies, there were remarkable similarities between PP and DS. The respondents’ estimated retention and reapplication rates were similar to previously reported studies. The comment section elicited numerous and lengthy comments, suggesting that sealant use is an area of preventive dentistry that is in transition. The solicited feedback revealed that practitioners have changed products and techniques multiple times in an attempt to improve their success ratios.

This survey demonstrated that sealant use among pediatric dentists has evolved toward the increased use of surface preparation and filled sealants, combining a restorative procedure with a preventive philosophy.

View larger version (121K): [in this window] [in a new window]   Dr. Primosch is a professor, Department of Pediatric Dentistry, University of Florida, Gainesville.

View larger version (133K): [in this window] [in a new window]   Dr. Barr is a pediatric dentist in private practice, 5150 W. 80th Ave., Westminster, Colo. 80030. Address reprint requests to Dr. Barr.