I am writing regarding the March JADA Association Report, "Evidence-Based Clinical Recommendations for the Use of Pit-and-Fissure Sealants: A Report of the American Dental Association Council on Scientific Affairs" (
Beauchamp J, Caufield PW, Crall JJ, et al. JADA 2008; 139[3]:257–268[Abstract/Free Full Text]
). If one assumes that at some point in the progression of a carious lesion that it is no longer appropriate to "seal" without excavation, then it is critical to know, before placing sealants, precisely the degree of carious progression.
After 30 years of practice, I still am occasionally surprised by a lesion that extends far beyond what I’d expected, on the basis of clinical and radiographic examination. What if I had sealed that tooth? Sadly, I also have had numerous occasions to remove sealants, only to find "bombed-out" teeth underneath. Yet, this article recommends that I diagnose and treatment-plan sealants without the benefit of an explorer or a radiograph. I have cleaned and dried teeth and then, when examining them under a microscope, have found food debris packed into the deepest grooves. I could, with difficulty, remove this debris with a very sharp explorer tip. Following this article’s recommendations, I not only could have sealed in caries, but also could have provided it with something to eat.
If, as the article states, sealants are effective at reducing occlusal caries by 76.3 percent (roughly three out of four times), then I can assume that sealants will not be effective in one out of four cases. Hence, if I seal four first permanent molars, should I expect caries to continue in one of those four teeth, with possibly disastrous consequences?
Given the stakes and the odds, I tell my dentist to feel free to excavate and remove all caries from my teeth. I advise my patients to allow me to do the same for them. Occlusal caries of the magnitude that one can hope to be effectively and predictably treated by sealants can be treated with minimally invasive composite or amalgam restorations following excavation. Only in this manner can we maximize our odds of success. In so treating, we can do far better than 76.3 percent for long-term success, with little need for replacement.
Have you ever had the experience of explaining to a parent that his or her child has extensive caries, despite having had sealants? Have you ever heard such a parent say something like, "But his/her teeth were ‘sealed against decay’"? My experience often has been that an invulnerability is assumed that does not exist.
The urge to put sealants on children’s teeth is a tidal wave I do not hope to stem. I urge all dentists to use their clinical judgment to decide for themselves whether it is a good gamble to seal teeth without knowing for sure the extent to which caries may lie underneath, in view of the fact that we can predictably, easily and comfortably treat occlusal caries with traditional excavation and restorative material and know, for sure, that we’ve treated it properly.
