We agree that many of the patients in our randomized clinical trial could have benefited from sealants. However, the question we are trying to answer relates not to sealants but to the benefits of early operative intervention into questionable carious lesions in the pits and fissures of posterior teeth.
Many factors need to be considered when deciding to intervene in an operative manner into a suspected carious lesion. If the questionable lesion does not need treatment—a false-positive diagnosis—then the unnecessary restoration will require a lifetime of maintenance.1,2
We feel that many patients do not understand or consider the fact that restorations require maintenance. We question whether patients realize that there often are additional costs or consequences in terms of time, lost tooth structure and possibly money due to this continuing cycle of maintenance and repair. As dentists, we feel we are responsible to inform our patients of this fact.
Another possible factor may just be coming to light. What is the progression of the 44 percent of the carious lesions that were found to have caries extending into dentin? Our initial research certainly indicates that the caries is progressing very slowly. Only time will tell if some of these lesions have ceased to progress (arrest) or even remineralize.
We were taught that the arresting or remineralization of caries that had progressed into dentin from a pit or fissure was not possible. How do we rationalize the following facts: 1) a fewer-than-expected number of carious lesions diagnosed in the control group and, more importantly, 2) that these lesions are not statistically and certainly not clinically different in size from the early treatment group? One has to question what we all previously believed.
The question that needs to be asked is: "How does the patient benefit from early operative intervention, either with a 
round bur, fissurotomy bur or air-abrasion handpiece?"
The current data indicate that there is no proven advantage, since the patient incurs a lifetime of maintenance for those restorations placed due to those false-negative diagnoses (56 percent), and, equally important, there is no difference in the size of the preparations if treated one year later.
When to intervene operatively into a suspected carious lesion in the pits and fissures of a posterior tooth is not an easy decision. Each patient is different, and each requires the best judgment of the clinician. In our randomized clinical study, which now is past the two-year recall period, early treatment has not conserved tooth structure and there has been no pre-or postoperative sensitivity in any treatment or control tooth. Also, the percentage of patients requesting local anesthetic is not statistically different when the early treatment and control groups are compared.
The question to those who want to provide early treatment is, "How long do we have to wait until we see a patient benefit from early treatment?"
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