We would like to thank Dr. Snaer for his very organized comments concerning our randomized clinical trial. We do not agree that the "results are suspect and its conclusion is not clinically applicable by a conscientious dentist." Conservation of tooth structure is surely a concern of a conscientious dentist.
We based our conclusion on the fact that there was no statistically significant difference (P = .279) in the volume of tooth structure conserved by early treatment. Equally important is the fact that 56 percent of the early treatment group did not require treatment by current standards (caries had not progressed into dentin), which would indicate that tooth structure was unnecessarily removed. This leads to further maintenance later for the patient. These factors are certainly a concern of a conscientious dentist.
Although some may think that "the element of air abrasion seems to be somewhat of a distraction in this study," there were good reasons to select air abrasion instead of small round burs. Air abrasion has been suggested by many authors as a means to treat small incipient carious lesions.1,2
Air abrasion allows a more pleasant treatment experience owing to reduced noise, vibrations and sensitivity. Air abrasion is closely linked to microdentistry, which is clearly related to conservation of tooth structure. For these reasons, air abrasion was selected over small rotary burs to prepare the preparations in both the early treatment group and the control group.
It is not clear to us what Dr. Snaer means by "faulty randomization." As was noted in our article, "after all evaluations were completed, the research coordinator used a table of random numbers to assign each enrolled tooth independently to either a treatment group or a control group." This is in accordance with published procedures for clinical trials.3
The concern that there was "no discussion in the article about how teeth in the control group were selected for treatment" was addressed in the subsection of the article entitled "Recall Evaluation, Methods and Materials." The article states, "If a control tooth was diagnosed with caries (softness, decalcification or cavitation at the base of a pit or fissure, or radiographic evidence of caries), we scheduled it for treatment, identical to that received by teeth in the original treatment group."
"The suggestion that increased remineralization due to greater availability of fluoride seems inappropriate" was supported by the reference below.4 There is an additional, more recent, reference noting that pits and fissures can remineralize.5
We would agree that the re-mineralization of pit-and-fissure caries with progression into dentin is not well-documented. In our randomized clinical trial we have seen teeth with a history at previous recalls of stained pits and fissures and significant resistance to the removal of an explorer, a criterion associated with caries progression into dentin in our trial (P = .006).
These teeth probably had caries into dentin based on significant explorer retention. At subsequent recalls, some of these teeth now have smooth "cavitated" areas that are hard when probed with an explorer, show no signs of decalcification, are not associated with any signs of a radiolucency on bite-wing radiographs and give low readings, around 15, with a laser fluorescence device.
This change from questionable carious lesions could be a result of the extensive explorer probing of the pits and fissures of control teeth, since they were probed by two dentists independently at each recall examination. If these patients were not part of the clinical trial, these deep pits and fissures would be sealed.
The suggested clinical implications by Dr. Snaer are simply not addressed by the research question: "Does early treatment of questionable carious lesions conserve tooth structure?"
The concern that sealants are not advisable is incorrect. We would feel comfortable sealing the pits and fissures of a large number of the control teeth in our clinical trial.6 The ones we would not seal would be in the older subjects, since age was negatively correlated with caries extending into dentin (P = .0313). Sealants would clearly conserve tooth structure, but were not included in the protocol because the question being studied was the conservation of tooth structure due to early operative intervention.
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