Viewing dental sealants through a wider lens

Preventive measure can enhance adults' long-term oral health

By Anne Nugent Guignon, RDH, MPH, CSP

In today's highly connected world, it's easy to exchange points of view with clinicians all over the world. Sometimes simple questions result in simple answers. And at other times simple queries generate deep, complex discussions that can get quite heated.

A couple of weeks ago, a young hygienist posed a seemingly straightforward question on a Facebook dental hygiene group. "Would you place sealants on first and second molars on a 19-year-old?"

My initial response was: "Why not? As long as a tooth has a vulnerable surface, why not place a sealant? I've placed sealants in adult mouths for years. Prevention does not have to stop at any age. There is a lifetime of risk that can include exposure to energy and sports drinks, medications that increase dry mouth, life style issues like tobacco and electronic cigarettes, biofilm issues, etc. Sealants are easy, simple, inexpensive."

Those of us who instinctively went straight to the "yes, why not" position justified our answers based on a simple premise that any virgin tooth is at risk for decay and therefore can and should be protected with a sealant. It seemed like a simple, straightforward answer to a very simple question. It took a little while for other points of view to start filtering in, and that is when the discussion got really interesting.

Some clinicians worried if dental insurance providers would even cover the sealants. Several indicated that if benefits were not available, sealants might not be recommended. Others began to chime in on that point. The young hygienist Vassy pointed out that before any treatment is proposed, a patient should have a proper clinical assessment to determine the actual need for a procedure, even a sealant. While making maximum use of benefits is important, treatment recommendations should never be based on a benefit package. One hygienist, Jackie, reminded the readers that if there is no coverage, remember to prepare the patient for the cost.

Jackie brought up CAMBRA, the caries management by risk assessment protocol. The entire focus of CAMBRA is based on relative risk for disease, not if a third party carrier will reimburse a procedure. She said "if you practice with CAMBRA protocols in mind, sealants are recommended at any age."

Kyle added even more reasons to consider sealing teeth whether the patient is 19 or 59. She pointed out that as people age, they are more likely to be taking medications that cause dry mouth; many patients over age 65 are dealing with chronic diseases that exacerbate dry mouth conditions. She also reflected that as people age, some people can have difficulty in performing their own oral hygiene procedures. Kyle sees inadequate oral hygiene every time she practices at a long-term care facility. Kathleen thought the decision should be based the individual situations, not age. Along with home care or loss of motor skills, Kathleen wonders if there is an increase in cariogenic foods or an access to care barrier.

The discussion then circled back around to the original question, which centered around sealing molars on a 19-year-old. Lisa chimed in with "a 19 year-old is a great candidate for preventive sealants. As kids move out, go off to college and spend those first years on their own, most also put dental care on the back burner. And their dietary habits are usually not the greatest." Her observations are well-supported by a number of studies involving the dietary habits of young adults.

Kim's thoughts summed up those of the majority. "Sealants are inexpensive and prevent decay, which is expensive. I'd rather avoid restorations at any age." Another hygienist, also named Kim, said her practice routinely recommends sealants for adults. She's even seen sealants on an octogenarian! Some hygienists in the discussion felt that if a person had reached adulthood without decay in occlusal surfaces, then the benefits from sealants were minimal; however, a number left the option up to the patient.

There were clinicians who opposed sealants because they had seen decay develop under sealants. One only felt comfortable using a clear sealant material, to allow a more direct post-application visual inspection over the years.

Then Molly, the original poster, added a critical piece of information. She works for two different doctors. One doctor seals teeth at any age, and the other only recommends sealants immediately after eruption. While many of our clinical decisions are judgment-based, especially when it comes to dealing with tooth structure, what a mixed message to a young dental hygienist! Interestingly, most of the hygienists who offered comments other than yes or no had practiced for 20 years or more.

And just like any other well-rounded discussion, there were no hard and fast "right answers." It was a wonderful example of mentoring via the internet.

Since it had been a long time since I had read much about the efficacy of sealants, I decided to take a stroll through PubMed, a well-respected resource operated by the National Library of Medicine. The database provides access to over 26 million scientific abstracts and papers on biomedical subjects. Despite the size, most of the research on sealants was conducted 25 to 35 years ago. And most of the papers only discussed sealant placement on the permanent molars of children and adolescents, but I did find nine papers published in the last six years that made some interesting points.

Liu et al. concluded that resin sealants are effective in preventing caries in the pits and fissures of permanent molars and over two years only 1.6% of molars treated with a sealant developed caries.¹ A 2014 study of sixty-four 7-to 10-year-old children reported clear sealants were 100% effective over the first year in managing occlusal surfaces and 98% effective at 44 months.² A 95% retention rate was reported for 1,511 sealants placed over a six-year period of time by dental hygienists in community public health department clinics. The dental hygiene clinicians used four-handed dentistry and strict isolation techniques.³ According to a study conducted by Antonson et al., there was no statistically significant difference between retention rates between glass ionomer and resin-based sealants at the end of a two year period of time. The authors reported a retention rate of 40.7% for resin sealants and 44.4% for glass ionomer.⁴

Population-based studies frequently review the cost effectiveness of providing a treatment, as compared to the long-term health outcomes of not providing a particular service. Placing sealants on primary molars initially costs more than not providing this preventive service, but sealing primary molars always reduced the number of restorations sevenfold over time. Never sealing a tooth leads to more restorative treatment over time and increased costs over time.⁵ Low reimbursement creates a disincentive for providing preventive procedures.^6,7 Female dentists select caries prevention therapies more often and at earlier stages than male dentists; nevertheless, there were few differences between the two genders in terms of diagnostic methods, time spent on restorative dentistry, fee structure, or practice business.⁸

An insightful article, by Gore published in 2010 in the International Journal of Dental Hygiene, offered a well-constructed discussion that made a case for using sealant therapy in the adult population. Occlusal surfaces make up 12% of the total tooth surfaces, but are eight times more susceptible to caries than smooth surfaces. Professional fluoride therapy provides protection against caries for smooth tooth surfaces, but must be applied multiple times a year every year. As a single procedure, dental sealants are the more cost-effective method for pits and fissures.⁹

Properly placed, sealants create a physical barrier that prevents microbes from colonizing pits and fissures. Sealants cut off the nutritional supply to the microbes so caries does not progress under an intact sealant. While the retention rate for a sealant varies per study, it is reported that dental sealants can last for seven or more years and can also be repaired or replaced to continue protecting the tooth surface. A 95% reduction in caries has been observed when 2% to 4% of existing sealants were repaired every year. ⁹

The risk for caries continues far into adulthood, and posterior teeth may be at risk indefinitely. Many geriatric and adult patients suffer from dry mouth issues, which increases the risk for both occlusal and root caries. Adding sealants to the adult prevention protocol provides a broader range of preventive service that supports a lifetime of good oral health.⁹

When sealants were first developed over forty years ago, the focus was on treating children and adolescents. There was a huge rush to seal every tooth, but often the actual mechanics of placing a sealant were short-changed. Early sealants only worked with sufficient etching, complete rinsing and applying the sealant material in a dry field. That was a tall order for those of us expected to work solo with a squirmy kid in the chair. But materials have changed to include sealants than can be placed in a moist environment and work as a continuous source of fluoride release. Isolation techniques have also improved.

A growing number of adults expect to keep their teeth for a lifetime. Given the breadth of the scientific studies and the increasing number of patients at risk, sealing adult molars and bicuspids is a valuable preventive service. We need to let go of our personal biases and let the patients choose whether or not to get their teeth sealed. We have a professional obligation to not limit our thinking by the mantra of "but that's the way we've always done it." RDH

ANNE NUGENT GUIGNON, RDH, MPH, CSP, provides popular programs, including topics on biofilms, power driven scaling, ergonomics, hypersensitivity, and remineralization. Recipient of the 2004 Mentor of the Year Award and the 2009 ADHA Irene Newman Award, Anne has practiced clinical dental hygiene in Houston since 1971, and can be contacted at [email protected].

References

1. Liu BY, Lo EC, Chu CH, Lin HC. Randomized trial on fluorides and sealants for fissure caries prevention. J Dent Res. 2012 Aug;91(8):753-8.
2. Fontana M, Platt JA, Eckert GJ, González-Cabezas C, Yoder K, Zero DT, Ando M, Soto-Rojas AE, Peters MC. Monitoring of sound and carious surfaces under sealants over 44 months. J Dent Res. 2014 Nov;93(11):1070-5.
3. Olmsted JL, Rublee N, Kleber L, Zurkawski E. Independent analysis: efficacy of sealants used in a public health program. J Dent Hyg. 2015 Apr;89(2):86-90.
4. Antonson SA, Antonson DE, Brener S, Crutchfield J, Larumbe J, Michaud C, Yazici AR, Hardigan PC, Alempour S, Evans D, Ocanto R. Twenty-four month clinical evaluation of fissure sealants on partially erupted permanent first molars: glass ionomer versus resin-based sealant. J Am Dent Assoc. 2012 Feb;143(2):115-22.
5. Yokoyama Y, Kakudate N, Sumida F, Matsumoto Y, Gilbert GH, Gordan VV.Dentists' practice patterns regarding caries prevention: results from a dental practice-based research network. BMJ Open. 2013 Sep 24;3(9):e003227.
6. Suga US, Terada RS, Ubaldini AL, Fujimaki M, Pascotto RC, Batilana AP, Pietrobon R, Vissoci JR, Rodrigues CG. Factors that drive dentists towards or away from dental caries preventive measures: systematic review and metasummary. PLoS One. 2014 Oct 8;9(10):e107831.
7. Carson SJ, Freeman R. Training and fairer payments would increase caries prevention in practice. Evid Based Dent. 2015 Mar;16(1):6-7.
8. Riley JL 3rd, Gordan VV, Rouisse KM, McClelland J, Gilbert GH; Dental Practice-Based Research Network Collaborative Group. Differences in male and female dentists' practice patterns regarding diagnosis and treatment of dental caries: findings from The Dental Practice-Based Research Network. J Am Dent Assoc. 2011 Apr;142(4):429-40.
9. Gore DR. The use of dental sealants in adults: a long-neglected preventive measure. Int J Dent Hyg. 2010 Aug;8(3):198-203.