Pit and fissure sealants
It is interesting to note that the genesis of the pit and fissure sealant dates to more than eighty years ago. Hyatt actually published that the the micro-tortuous convolutions of enamel on the occlusal table contributed significantly to the generation of caries. He proosed that this clinical problem could be reduced by what he termed “prophylactic odontonomy”. (Hyatt TP. Prophylactic odontonomy. Dent Cosmos, 1923; 65:324-241). Widening of the fissures could in effect reduce the potential for harboring caries producing microbes. This concept was reintroduced several decades ago but now generally has been put aside.
In the sixties a number of fluoride containing agents were marketed for the purpose of diffusing the fluoride ion into the enamel surface Examples included HL 70 and 72. (Merrill, S.A., Leinfelder, K.F., Oldenburg, T.R. and Taylor, D.F.: Methods of evaluating pit and fissure sealants, J. Dent. Child 42:123, 1975). While the concept appeared appropriate, the sealants did not stay on the tooth long enough for the fluoride ions to impart any caries resistant benefits. Other materials including cyanoacrylates and polyurethanes were also tested but to no avail.
The greatest success came about with the introduction of Bis-GMA (Bowen’s resin) as a sealant material in the early 1970’s. (Silverstone LM. Operative measures for caries prevention. Caries Res, 1974; 8(Suppl 1):103-112). The initial sealants made with this formulation were cured with ultraviolet light. Finally, the introduction of visible light also made its way into the curing of pit and fissure sealants. This particular formulation (Bowen’s Resin) continues to be used at the present time. However, as will be pointed out subsequently, low viscosity dentin bonding agents have also been shown to be effective as a pit and fissure sealant.
Although the efficacy of pit and fissure sealants has been demonstrated in a large number of studies, the profession has been surprisingly slow in accepting this mode of preventative treatment. (Gwinnett AJ. Pit and fissure sealants; an overview of research. J Public Health Dent, 1982; 42(4):298-304; Silverstone LM, the use of pit and fissure sealants in dentistry; present status and future developments. Pediatr Dent, 1982; 4:16-21). Although there may be numerous reasons for this state of affairs, some of the more important include the clinician’s skepticism over efficiency, accidentally sealing over active caries and the fact that dental insurance companies are reluctant to cover this form of treatment. In addition, the reason that insurance carriers are third party providers do not favor reimbursement of sealants relate to their concern that the practitioner may lack the ability to place the material properly. Finally, since the insurance companies are reluctant to cover the cost of pit and fissure sealant application, the clinician do not get excited about recommending them to some parents.
Nearly all of the literature demonstrates that pit and fissure sealants are effective in reducing the level of caries. The procedure should be part of every clinician’s armamentarium. Now, the question that must be asked relates to their cost effectiveness. In the private practice sector that is a very difficult question to answer. In fact, the literature tends to stay away from answering this question. However, Simonsen did publish some information about two decades ago where he assessed the costs of treating children with sealants in a health maintenance facility in Minnesota (Simonsen RJ. The clinical effectiveness of a colored pit and fissure sealant at 36 months. J Dent Res, 1982; 61:332). His results revealed a high degree of retention. Specifically the value was 82% after 5 years on a single application. He calculated that the sealant group cost about ten dollars per child as opposed to over 21 dollars for children in the control group (no sealant protection).
All of this seems straightforward and clear-cut. However, the massive introduction of systemic fluoride has reduced considerably the carries rate in children up to the age of 18 (and beyond). The question then is “Should pit and fissure sealants continue to be recommended by the clinician”? The answer of course is yes. However, some qualification of this statement should be offered. While the general use of sealants previously had been recommended for all children, that case might no longer be true. Perhaps sealant application should be considered when there are specific reasons. Some of the more apparent ones include: 1) evidence of caries at any level, 2) unusually slow eruption rates, 3) placement of orthodontic appliances, 4) less than adequate oral hygiene, 5) patients that are physically and/or mentally handicapped and 6) patients that are unwilling or incapable of being available for treatment on a routine basis.
Incidentally, sealant protection has actually been imporved through the introduction of dentinal adhesives such as the current generation of dentin bonding agents. Due to their very low viscosity, these agents not only deal with the ends of the enamel rods but they also readilty penetrate into the interprimatic spaces.
Karl F. Leinfelder
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