We thank Dr. Lodico for his comments on the March JADA evidence-based clinical recommendations on pit-and-fissure sealants. We concur with Dr. Lodico that clinicians should incorporate their clinical judgment into applying the clinical recommendations. In fact, the recommendations state that "as part of the evidence-based approach to care, these clinical recommendations should be integrated with the practitioner’s professional judgment and the patient’s needs and preferences."
These recommendations were developed through a critical assessment of all available evidence by a panel of experts. Each recommendation is based on the best available evidence. For the issue of sealing over noncavitated lesions, the best available evidence consists of two recently published systematic reviews of clinical studies, the highest level of evidence possible.1,2
The clinical recommendations indicate that sealants should be placed only on early, noncavitated, carious lesions. Such lesions are defined in our article as "pits and fissures in fully erupted teeth that may display discoloration not due to extrinsic staining, developmental opacities or fluorosis ... [with] no evidence of a shadow indicating dentinal caries, and, if radiographs are available, they should be evaluated to determine that neither the occlusal nor proximal surfaces have signs of dentinal caries." Figures 1 through 5 on page 265 illustrate these types of early, noncavitated lesions.
Any tooth that contains a cavitated lesion or any signs of dentinal decay is excluded from the recommendation. The recommendations go on to state that sealants must be monitored and maintained in order to maximize effectiveness.
The recommendations state that an explorer is not necessary for the detection of early lesions and caution that forceful use of a sharp explorer can damage tooth surfaces. But there is no evidence-based recommendation against the use of an explorer. Likewise, the recommendations state that radiographs should be used if they are available, and that the ADA/U.S. Food and Drug Administration Guide to Patient Selection for Dental Radiographs should be applied.3 But, if radiographs are not indicated for other reasons, they need not be obtained for the sole reason of placing sealants.
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