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Pit and fissure sealants: a review of the literature.

Introduction

Over the past two decades, scientific research on pit and fissure sealants has established its efficacy as a primary preventive procedure and its importance in managing dental caries. Therefore, oral health care professionals must become familiar with this research if they are to recommend and utilize sealants.

Development of Sealant Materials

The concept of sealing the fissures of teeth to prevent caries is over 100 years old. In 1895, a report in Dental Digest by Wilson[1] described the use of oxyphosphate cement to seal fissures. While this procedure did not provide long-term protection, it did introduce the concept of preventing dental caries in teeth fissures using a physical barrier.

In the years to follow, attempts by Hyatt,[2] Bodecker,[3] Kline and Knutson[4] and Ast et al.[5] to find a sealing material that provided long lasting barrier protection met with limited success. A notable breakthrough in the development of effective sealant materials occurred in 1955, when Buonocore[6] reported the use of acid to etch the enamel surface prior to applying acrylic resin. The acid-etch technique allowed for sufficient bonding between the resin material and enamel, and provided the basis for further development of effective sealant materials.

In 1976, the Council on Dental Materials of the American Dental Association (ADA) designated sealants as a safe and effective means of preventing pit and fissure caries.[7] Subsequent research and manufacturing efforts produced a variety of sealant materials, including autopolymerized or visible-light polymerized; semi-filled with inert particles or unfilled; with or without fluoride; and clear, tinted, or opaque.

The literature also contains various recommendations for surface preparations and cleaning the occlusal surface prior to sealant placement, including use of hydrogen peroxide, pumice, water, air polishing a sharp instrument tip, or a bristle brush.[8-12] Analyses of these variables indicated no significant difference in retention of sealant, regardless of method used. Acid etching appears to sufficiently remove the minimal pellicle, and cleanse pits and fissures.[13] In some cases of poor oral hygiene, plaque, debris, and stains should be removed to evaluate the condition of the tooth surface.[14]

Two studies indicated no significant difference in retention of sealant related to the use of liquid versus gel etchant.[15,16] Recent research investigating other enamel conditioning methods, such as air abrasion and carbon dioxide laser techniques, has been conducted to determine their effectiveness in sealant applications.[17-21]

Two variables most likely to affect the efficacy and retention of a sealant are the clinician's ability to use proper application/isolation techniques and the eruption status of the tooth.[23-25] Clinicians must follow the recommended etching and curing times while maintaining a dry field of operation. The most common cause of sealant failure is generally agreed to be moisture contamination during application.[26]

To ensure adequate isolation, complete eruption of the tooth is preferable. Dennison et al.[25] found that posterior teeth with the operculum covering the distal marginal ridge of the occlusal surface were twice as likely to need sealant replacements than those with the marginal ridge exposed.

Additional considerations regarding sealant materials include the effects of fluorides and air polishing on existing sealants, and the need for occlusal adjustment. A study was conducted to determine the effect of topical fluorides (both acidulated phosphate fluoride and neutral sodium) on semi-filled and unfilled sealants, and glass ionomer materials. Results indicated that acidulated phosphate fluorides may cause deterioration of semi-filled sealants and glass ionomers, but not unfilled sealants.[27] Studies of the effects of air-polishing on self- and light-curing sealants found no statistically significant loss of sealant materials due to air polishing.[28]

The need for occlusal adjustment following sealant placement was investigated by Tilliss et al.,[29] who suggested that natural wear of unfilled sealants is sufficient to establish appropriate occlusion, while use of a semi-filled sealant material requires checking the occlusion and possible adjustment of the occlusal contacts.

A recent study reported that bis-GMA based sealants appeared to contribute to human exposure to xenoestrogens. Researchers applied bisphenol-A-based sealants to the molars of 18 college-aged volunteers. They compared saliva samples taken before and after treatment and found bisphenol A present in the post-treatment samples.[30] Concerns about bisphenol A leaching after sealant placement lead to Hamid and Hume[31] studying the in vitro release of bisphenol A. They reported that the chemical could not be found in eluates from any sealant tested. Further research is necessary to establish whether there are adverse consequences of using bisphenol-a-based sealants.

Retention and Effectiveness

The primary factor associated with the efficacy of sealants is their ability to remain bonded to the occlusal surface. Weintraub's[32] review of sealant effectiveness compared retention, caries incidence, and reapplication rates reported in numerous studies. Based on the results of this comprehensive work, the author concluded that: 1) children and young adults experience a high rate of occlusal caries (80-90%) and a relatively low rate of proximal caries (10-20%); 2) the benefits of large-scale sealant programs decline with increasing age; 3) after one application, the percent of effectiveness and complete retention declines over time -- median effectiveness and retention rates were 83% and 92%, respectively, after one year, which declined to 55 and 66% after seven years; 4) there was no significant difference in benefits of sealants between Studies of fluoridated and fluoride-deficient communities; 5) studies comparing reapplication rates and restorations indicate that reapplication of a sealant is needed to maintain its preventive effect over time. The studies Weintraub reviewed indicate that completely retained sealants prevent decay, but sealants that are lost should be reapplied.

It has been suggested that a tooth without decay four years after eruption is not likely to decay in the future. This theory no longer appears to be valid.[33,34] Several researchers investigated the risk of occlusal caries throughout life and found continuing caries susceptibility.[35,36] These findings suggest that children may benefit from sealants, even when teeth had erupted several years prior, and that reapplying sealants throughout life may be beneficial.

Simonsen[37,38] studied sealant retention using a retrospective case-control study of children with permanent molars. Among those who received a single application of a white-colored autocured sealant in 1976, 74% of the pit and fissure surfaces of permanent first molars were non-carious 15 years later. Simonsen noted that, although he only had looked at studies of a single application of sealants, children can potentially maintain caries-free molars through timely reapplication of sealants.

A clinic-based sealant program was conducted for Guamanian children in grades one through eight to reduce caries rates on this fluoride-deficient island.[39] Sealants were applied to the teeth of over 15,000 children from 1984 to 1986. Decayed, missing, and filled surfaces scores (DMFS) were reduced by 45%. In addition, the first annual evaluation indicated a sealant retention rate of 94 percent.

The effectiveness of sealants when applied in dental practices rather than clinical trials or public health programs was examined by Ismail and Gagnon.[40] In 1990, a random sample of children (n=733) aged 6 to 9 was examined over a two-year period in Quebec to evaluate sealants in private dental practices. Sealants on 600 occlusal surfaces of permanent first molars were determined to be fully sealed. After two years, 73.5% were still fully sealed. Compared with unsealed sound molars, the fully sealed teeth had a 75% lower incidence of new restorations.

In another study, of retention rates, Romcke, et al.,[41] evaluated 8,340 chemically cured sealants placed between 1978 and 1985. After one year, complete retention was found on 89% of the teeth; 60% after seven to nine years. Six percent needed maintenance sealing after one year, while sealant removal was required for only 1% due to occlusal caries and 2% due to interproximal caries. These studies suggest that sealants can effectively prevent dental caries when applied in private practices.

Incipient Caries and the Use of Sealants

In the mid-1980s, based on research findings demonstrating that intact sealants halted caries progress, a consensus panel convened by the National Institute of Dental Research (NIDR) endorsed the use of sealants on incipient caries.[42] Viewed from the perspective of the medical model of disease, dental caries is a preventable infection primarily caused by Streptococcus mutans. Research on the use of sealants over incipient carious sites has shown consistently that bacteria tend to die out and caries do not progress when early infections are sealed.[43-50] One study indicated that viable bacteria decreased by as much as 98% after being isolated under a sealant for two years.[49] In addition, radiographic and audio-pressure transduction investigations have found that caries ceased in sealed incipient infections.[45,51-53]

Longitudinal evaluation of sealant effect on the caries experience of initially sound and incipient lesions was completed on 96 children in a public health program.[54] After five years, the initially incipient surfaces that were sealed had a 10.8% caries rate while unsealed surfaces reached 51.8%. Initially sound surfaces had a decay rate of 8.1% for sealed surfaces and 12.5% for unsealed. The authors concluded that sound tooth surfaces did not appear to benefit greatly from sealants and recommended sealing of incipient surfaces to reduce decay rates.

Inadvertent sealing of incipient lesions should not be a clinical concern and, in fact, these surfaces should be sealed first. As long as the sealant margin is intact, bacteria decrease and caries should not progress. Improvements in caries diagnosis, case planning, and treatment have important implications for sealant use. Anusavice[55] recommends that the decision-making process for restorative treatment include a consideration of sealants and preventive resins.

Glass Ionomers

Studies of the use of glass ionomer (polyalkenoate) as a fissure sealant indicate significantly lower retention rates than resin-based fissure sealants.[56,57] However, the rate of reduction in caries is similar for each material. van Noort[58] Suggests that, although the glass ionomer appears lost, some material may be retained in the fissure an, continues to prevent caries. Overbo and Raadal[59] compared the extent of microleakage that occurs in glass ionomer cement and a diluted composite material. Extensive leakage was found in the glass ionomer cement throughout the material, and at the margin of the cement and the enamel; no leakage was found in composite specimens.

The use of glass ionomers has been suggested for erupting teeth where isolation from saliva is a problem and caries risk is high: however, further research is needed to determine the long-term benefits of this approach.[60] A clinical study involving intentional salivary contamination indicated that sealant retention is possible on wet enamel if a bonding agent is used between the enamel and sealant.[61]

Restorative Materials

The effect of sealing over newly placed dental restorations has been investigated in an effort to extend the life of such restorations.[62,63] If microleakage can be reduced by sealing the margins, the need for replacement of restorations would be minimized. Replacing restorations usually involves further removal of tooth structures, which weakens the tooth and can lead to fracture.

Comparing surfaces restored with composite and sealed, amalgam and sealed, and amalgam but not sealed, showed that covering a new restoration with sealant can be beneficial.[64] Amalgam restorations sealed with a pit and fissure sealant exhibited significantly less microleakage and superior marginal integrity. Composite restorations with sealant prevented caries effectively for four years.

Anderson[65] proposed a technique using sealants to repair the fractured non-carious margins of existing amalgams in order to increase their longevity.[65] With proper surface preparations and appropriate selection of a sealing material, the ditched margins of amalgams can be repaired to effectively prevent microleakage and preserve the existing restoration.

Orthodontic Care

Use of sealants with orthodontic care may reduce enamel demineralization at the margins of bands. Liebenberg[66] Suggested that fissure sealants cover the occlusal surface and any open margins between the band and tooth to eliminate the iatrogenic defect created by the band-tooth interface. It was suggested that this technique could reduce the demineralization that results from insufficient bonding of the cements and their solubility in oral fluids.

Banks and Richmond[67] performed a clinical test using two enamel sealing systems (viscous and non-viscous) to prevent enamel decalcification following bracket bonding. Results indicated that 75% of the 80 participants were affected by enamel decalcification. Use of the viscous sealant produced a 13% reduction in demineralization, while the non-viscous sealant produced no significant difference. The authors recommended continued research to reduce the risk of orthodontic treatment.

Cost Considerations

As health care costs continue to rise, there is an increasing need to promote effective preventive measures. There have been limited studies to determine the cost-effectiveness of sealants.[68,69] Kuthy[70] examined dental insurance claims for over 1.3 million children over a three-year period -- to 1986 1988 -- and found that the average one-surface restoration charge more than doubled the average sealant charge. A similar ratio was found in survey data published by the Bureau of Economic and Behavioral Research of the ADA.[71,72] Perhaps more significant than the difference in initial cost is the potential for reducing of long-term dental treatment expenses.[73,74]

Utilization Patterns

Sealant use has increased gradually but remains relatively, low, especially considering its potential to prevent caries. Widespread use has been constrained by a lack of consumer knowledge, a low level of provider awareness and acceptance, and a lack of public access to professional preventive services.[32,75,76]

Surveys in the 70s and early 80s indicated that 40 to 60% of dentists used sealants.[77,78] A 1986 survey indicated that 81% of dentists used sealants, but 66% applied them to only five or fewer patients per week.[79] Similar usage patterns were evident in a national survey of pediatric dental practices, where 55.4% of practitioners used sealants but applied them to less than half of their pediatric patients.[80] More recent surveys indicate up to 90% of practitioners report using sealants, but defining actual usage in the future necessitates determining how frequently each practitioner places sealants.[81,82]

The data that most clearly suggests an underutilization of sealants are in reports of sealant prevalence in schoolchildren. NIDR's 1985 - 86 survey of US schoolchildren indicated that only 7.6% had sealants.[83] Sealant prevalence in children, adolescents, and adults reported in the 1988-1991 Third National Health and Examination Survey (NHANES III- Phase 1) indicated that 18.5% of children and adolescents aged 5 to 17 had one or more sealed permanent teeth, and only 1.4% of adults aged 18 and over had a least one sealed tooth.[84]

In 1990, in an effort to increase sealants in private and public health settings, the US Public Health Service established a dental health objective of 50% of children ages 8 and 14 to have sealants on one or more permanent molar teeth by the year 2000.[85] In conjunction are efforts to increase awareness of sealants and their efficacy. In April 1994, guidelines for sealant use were written by a workshop of 22 clinicians, policy makers, program administrators, and oral health researchers in the Journal of Public Health Dentistry.[86] The guidelines provide important recommendations to establish sealants in individual care and community health programs.

In 1994, sealants were promoted by: 1) the National Public Health Dental Sealant Program Conference in Columbus, Ohio, which was attended by dental health representatives from 35 states and two territories (featuring the first presentation of the recommendations of the Workshop on Guidelines for Sealant Use); 2) a national survey of public health sealant programs conducted by the Ohio Department of Health; 3) development of the "SEAL AMERICA: the Prevention Invention" videotape and manual, which provided instructions for developing and operating school-based sealant programs; 4) funding of the national school-based Oral Health/Dental Sealant Resource Center at the University of Illinois at Chicago School of Public Health to promote sealant programs nationwide and serve as a resource for dental sealant programs.[87]

Numerous researchers have sought to identify the reasons why sealants are underused. Surveys of adoption patterns, use of auxiliaries, perceived barriers, attitudes, and knowledge indicate that practitioners may not be familiar with sealant literature.[77,88-96] This is most notable in surveys of perceived barriers to using sealants. Results indicate continued misconceptions, despite the accumulation of scientific research to the contrary. The most frequently noted misconceptions included the supposition that sealants are easily lost or seal in decay; that patients resist the expense, prefer amalgam restorations, or do not understand sealant value; and that sealant effectiveness is not proven.[77,90]

Data collected from the NHANES III, 1988-91 national survey indicated an increase in sealant prevalence.[84] A study of Ohio dentists found that the percent of sealant users increased from 1989 to 1992 and that lack of insurance coverage was identified as the major barrier to patients receiving sealants.[97]

Dental Hygienists' Knowledge and Use

Most state dental practice acts permit sealant placement by dental hygienists.[98-101] However, delegation of sealant application is low.[77,102,103] Research has shown that dental hygienists and dental assistants can apply sealants effectively and that the procedure should be delegated to them. [103-106] In addition, numerous studies establish the cost-effectiveness of sealants being applied by dental hygienists and dental assistants.[108-111] Future research on this topic may indicate an increase in delegation of sealant application from earlier years.

A study of dental hygienists practicing in Minnesota and Wisconsin investigated their knowledge, opinions, and use of sealants.[112] These baseline data were collected prior to the 1983 NIH Consensus Development Conference on Dental Sealants in the Prevention of Tooth Decay. Results indicated that 64% of Minnesota hygienists and 84% of Wisconsin hygienists were not applying sealants. Among dental hygienists who did place sealants, their frequency of use per week was low; only 5 and 4% of Minnesota and Wisconsin hygienists, respectively, reported placing them more than 3 times per week. Responses to an open-ended question to determine reasons for nonuse indicated that Minnesota hygienists were most likely to mention lack of employer acceptance or a nonpermissive office policy. Wisconsin hygienists mentioned sealants not being applied in the office and a lack of employer acceptance or nonpermissive office policy. Other reasons were a lack of training, resources, and equipment; the employer applied or did not delegate the responsibility for application to the hygienist; and the patient or parents lacked understanding. The reasons for nonuse reported by hygienists differ from those given by dentists, who focused the lack of acceptance on concerns about technical procedures.

In 1983, a nationwide study of dental hygienists who had graduated one year earlier indicated that the majority of respondents never applied sealants.[113] Seventy-four percent did not apply sealants for adult patients and 60% did not apply sealants for children. The authors associate this with low levels of self-perceived competency in providing sealants and employers' negative attitudes and reluctance to delegate. They recommended that dental hygiene education programs provide more extensive experience in applying sealants to facilitate the competence and willingness to negotiate with employers to delegate this preventive service. However, since sealant prevalence increased after this recommendation was made,[83,84] educational programs may have implemented the recommendation.

In a 1985 study of sealant use by dental hygienists in Virginia, 53.1% reported receiving experience (theory, laboratory, or clinical) in sealant application during their professional education.[114] This compared to 50% of pediatric dentists and 28% of general dentists reporting. The study also found that 68.6% of dental hygienists who worked in general practice said they applied sealants. The most frequent reason given for not applying them was that the dentist did not believe in their use. The authors concluded that a lack of professional knowledge about sealants existed and recommended additional basic and continuing education for students and practitioners respectively.

Public Knowledge and Acceptance

The general public's knowledge of oral diseases and their prevention were investigated by Gift et al.,[115] using data from the National Health Interview Survey (NHIS). Results indicated that racial and ethnic minorities and groups with low levels of formal education demonstrate the least knowledge of prevention of oral diseases. Only one-third of adults had heard of sealants and 25% of those adults could not correctly identify the purpose of sealants.

NHIS data suggested that both the pattern of dental visits and use of sealants are strongly associated with socioeconomic status.[76] In that survey, children in low income and education categories experienced fewer dental visits and had fewer sealants, due to a lack of funds, knowledge, insurance, and access to preventive dental services.[76,116]

Because public/community sealant programs can provide effective preventive strategies to target specific populations such as low-income children, the importance and use of these programs are expanding. Cohen and Horowitz[101] reported an increase from 21 to 29 in the number of states with community sealant programs between 1985 and 1991. By 1994, all 50 state Medicaid programs reported providing reimbursement for sealants.[117]

Many school-based sealant programs that target children were established in response to the Healthy People 2000: National Health Promotion and Disease Prevention Objective, which set a goal of 50% of children ages 8 and 14 years having at least one permanent molar sealed by the year 2000.[85] Implementing school-based sealant programs can provide access to care for children who are at high risk or whose parents have limited financial resources for preventive dental care.

Public awareness of sealants significantly affects whether a child has them applied. Parents must know about sealants before they can make an informed choice. Surveys of parents' knowledge of sealants indicated that dentists and dental hygienists are the most frequent source of information about sealants.[118-120] Selwitz found that parents were more likely to obtain sealants for their children if the dentist or a staff recommended them.[119] A study conducted shortly after the NIH conference[121] reported that mass media also served as an important source of public information about sealants.[122] Horowitz and Frazier[98] recommended public education programs from as many sources as possible to increase the demand for sealants.

A survey of physicians and teachers in Utah indicated that 68% of physicians were unfamiliar with sealants; and while most dental health teachers taught brushing, flossing, and low-sugar diets, less than 20% included information about sealants. This study also investigated the influence of insurance coverage for sealants on parents' decisions to have sealants for their children. Of the 627 respondents, 44% of urban and 39% of rural parents indicated they would have sealants placed whether or not insurance covered any of the Cost.[81]

In reviewing the societal and professional factors associated with use of sealants, Frazier[97] stated:

"although national health policy today

recognizes the rights of patients and

consumers to be accurately and fully informed

about procedures available to protect their

health and to give informed consent for

treatment procedures performed,

information about sealants has been all but hidden

from public view."

To increase awareness and use of sealants, Frazier recommended improved communication among dental researchers, dental educators, practitioners, and dental licensing boards, all of whom are obliged through employment, position, or public licensure to act on behalf of the public interest.

Conclusion and Recommendations

The scientific research conducted over the past 25 years clearly has established the effectiveness of pit and fissure sealants in preventing occlusal caries. Their demonstrated effectiveness notwithstanding, sealants continue to be underutilized as a method of disease prevention, particularly for school-age children. Because the literature reviewed in this article suggests that the potential to markedly reduce the incidence of dental caries through use of pit and fissure sealants has not been realized, the following recommendations are made:

1) Advocate caries management curricula in dental and dental hygiene education, which encompass the clinical, behavioral, preventive, ethical, and philosophical aspects of preventing infectious disease. 2) Encourage practicing clinicians to participate in caries management courses to close the "gap" between what we know as health care professionals and what we actually do as clinicians. 3) Develop public education programs to ensure that parents and caregivers are aware of the availability and efficacy of pit and fissure sealants. Activities could include a) use of media, such as television, radio, newspapers, parents' magazines, child health care books, and children's storybooks; b) provision of educational programs for parental groups, school health educators, school and public health nurses, family practitioners, pediatricians, and pediatric nurses; and c) use of educational displays at local libraries, child health care centers, women's health centers, child daycare centers, community and school health fairs, hospital pediatric units, and pharmacies. 4) Provide accurate information and education to insurance providers and business administrators about the benefits of sealants. This can be facilitated by providing sealant education materials for employee bulletin boards, paycheck stuffers, and company wellness programs. 5) Continue research studies that a) develop even more efficacious sealants, b) determine factors associated with clinical sealant use by oral health care providers, c) evaluate the lifetime benefits for individuals who have sealants, and d) develop standardized assessments of the actual frequency and number of sealants being placed. 6) Organize dental health professionals to assess the dental needs in their local communities. Developing or collaborating with existing public health programs can be useful in establishing access to care for targeted populations with limited financial resources and/or high risk of dental disease. Involving dental health professionals is important to the implementation and success of community and school-based dental care programs. 7) Utilize existing sealant education resources and materials to provide consumers and health professionals with accurate information.

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Joan L. Gilpin, RDH, MA, is a private-practice dental hygienist in Waverly, Iowa, and adjunct dental hygiene instructor at Hawkeye Community College, Waterloo, Iowa.
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Date:Jun 22, 1997
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