My thanks and appreciation to Drs. Gureckis and Overton for their contribution to the profession’s understanding of the conservative management of incipient occlusal caries.
I am sure that we are in agreement that the key to "arrested caries development" beneath an intact sealant is retention of the sealant. Five years ago, a study by Clinical Research Associates1 concluded that there often is significant caries beneath nonmaintained sealants. In fact, it found that if sealants were placed years earlier and were not maintained, teeth were always carious.
One must always consider the measurable failure rate of sealants (between 5 and 10 percent per year). Even under the best of circumstances, sealants fail.2 The reality is that sealants are only 100 percent effective in preventing pit and fissure caries if they are completely retained.
One early study reported that 21.7 percent of sound and sealed first permanent molars became carious or filled after 10 years.3 Another study reported that 15 years after the single application of white-colored pit and fissure sealant to permanent first molars, only 27.6 percent of the sealants were completely retained, and 35.4 percent were partially retained.4 In other studies, the retention rate was 92 percent after one year, and only 67 percent after five years. 5
Clearly, then, if one chooses to leave "arrested caries" at the time of sealant application, then sealant retention should be checked regularly, and teeth should be resealed as needed. Sealants must be retained adequately to be effective.6
There is another disturbing phenomenon associated with sealants. The Journal of the Massachusetts Dental Society reported that the widespread use of sealants often masks the progression of occlusal caries deep within the associated pits and fissures, further compounding the difficulty of early and accurate diagnosis of lesions. The study also showed that, left undiagnosed, caries progresses undetected in the dentin of otherwise apparently healthy sealed teeth, with disastrous results.7 Unfortunately, I believe that most general practitioners have witnessed this process many times during their careers.
A number of studies have questioned the advisability of placing a sealant over caries, particularly when the caries extends into dentin.8 What, then, is to be done? In 2000, White and Eakle9 reported that the minimally invasive surgical approach allows the clinician, with only slight loss of sound tooth structure, to examine the fissures directly to detect caries. Should caries be discovered, this approach requires only very conservative tooth preparations. In the absence of caries, the patient will have nevertheless received the best possible mechanically-prepared sealant. To accomplish this, as Clinical Research Associates10 reported, air abrasion could be employed for preparation of teeth that are to receive sealants.
The ADA Council on Access, Prevention and Interprofessional Relations11 has emphasized that utilizing conservative restorative procedures could do much to preserve tooth structure, and has indicated that, in instances in which the presence of pit or fissure caries is suspected, the minimal exploration of the fissure pattern with a small round bur might be employed so that a more definitive determination could be made. In the absence of caries, a sealant might then be placed.
Ultimately, the decision to place a sealant or a minimally invasive resin restoration depends on the professional judgment of the dentist, for a specific patient at a specific time. The ADA12 has emphasized that the decision to use sealants on sites containing known enamel lesions is the responsibility of the dentist.
In response to the second part of their letter, let me say that, six years ago, the Journal of the Canadian Dental Association reported that bacteriological sampling of early dentin lesions provides little reason to believe that we can effectively seal in caries when present.13 Thirty-two years of clinical experience make me hesitant to leave infected dentin within the outline of the sealant or cavity preparation, especially when very conservative mechanical instrumentation may be utilized to eliminate it.
Caries detection dye will positively stain areas of infected dentin within the outline of the sealant or cavity preparation. Numerous studies have demonstrated the effectiveness of dyes in identification of infected dentin.14–19 They are nearly unanimous in their opinions that caries detection dye is a reliable diagnostic tool for carious lesions that should be removed prior to placement of a sealant or a restoration.
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