Encouraging Sealant Use

Childhood and adolescent caries continues to be one of the most common chronic diseases, impacting youth around the world.¹ In light of the myriad health challenges presented by the COVID-19 pandemic, discussion of caries prevention and management is not front and center. However, educating families and patients about how this disease can be prevented remains important.

FLUORIDE: THE GOLD STANDARD

A 2015-2016 National Health and Nutrition Examination Survey reported the prevalence of dental caries in both primary and permanent teeth among those ages 2 to 19 was an astounding 45.8% in just the United States.² Fortunately, established clinical guidelines and best practices are available to help prevent and decrease the occurrence of dental caries. To date, systemic and topical applications of fluoride are the most effective treatment modality in preventing caries.³ Community water with optimal fluoridation is the safest and most cost-effective means of caries prevention especially for individuals with existing barriers to regular oral healthcare.⁴ Approximately 73% of the US population has access to fluoridated community water.⁵ Skepticism, concerns about the safety of tap water, and public health catastrophes such as the Flint water crisis, have deterred many low-income communities from reaping community water fluoridation’s anti-caries benefits. In 2018, only 10% of Americans reported using tap water exclusively; the corresponding spike in the consumption of bottled water has led to an increase in tooth decay.^5,6 For the same reasons, parents are hesitant to follow through with professional, in-office fluoride treatments. In light of the underutilization of fluoride, oral health professionals must explain the importance of preventive treatment methods—such as in-office fluoride treatment and dental sealants—to their patients in order to mitigate childhood and adolescent caries development.

Sealants are the best choice for prevention and treatment of sound and noncavitated carious lesions on occlusal surfaces with deep anatomical grooves, pits, and fissures.^7,8 Since their development in the 1960s, sealants have been used as a physical barrier to seal off the tooth’s pits and fissures from invading bacteria that create the acidic environment which initiates caries development.^9,10 The physical barrier created by sealants can also impede noncavitated carious lesions from further progressing into the dentin and even arrest moderate carious lesions.^11,12 Unfortunately, even with years of clinical research supporting sealants, they are still being underutilized in clinical practice. This may be due to a lack of confidence in knowing when to seal, what teeth to seal, and which material to use. Or perhaps, parents’ attitudes and lack of knowledge about sealants play a role in their underutilization. As such, clinicians need to understand evidence-based guidelines for the use of pit and fissure sealants and be able to thoroughly explain this recommend preventive treatment option to parents. 

TYPES OF SEALANTS

For most clinicians, choosing the correct type of sealant material may be overwhelming. The three major sealant material types are: resin-based sealants (RBS), glass ionomer sealants (GI), and polyacid-modified resin sealants. 

RBS are commonly used in clinical practice and most contain bisphenol A-glycidyl methylacrylate (Bis-GMA). They can be further classified by methods of polymerization, filler content, and color. ^7,13 Fluoride-releasing particles can be added to light-polymerizing RBS to further prevent caries, although more research is needed to demonstrate their efficacy.¹³ Many clinicians believe that filled RBS are superior to unfilled sealants due to their increased wear strength. However, there are drawbacks to filled RBS, including lower penetration rates into pits and fissures and the need for occlusal adjustment. ¹³ Most RBS require a dry field prior to placement, although one RBS product can be placed in a moist field. 

Parents may resist sealant placement due to concerns about bisphenol A (BPA) exposure. BPA levels do increase for up to 1 hour post-sealant placement, but these levels then decrease to normal base values.¹⁴ The following recommendations should be followed to minimize BPA exposure during sealant placement:¹⁴

1. Use a rubber dam to minimize dissolution of BPA in the saliva.
2. Perform a 30-second air/water rinse post-placement in addition to using a cotton tip applicator or cotton roll to wipe the sealed surfaces to eliminate the last layer of resin unpolymerized by oxygen.
3. Place up to only four sealants at a time. 

Parents need to understand that humans are exposed to a greater amount of BPA on a daily basis through food, air, cosmetics, and thermal receipts; therefore, the benefits outweigh the risks in sealant placement.^13,15

GI sealants are cement-based and widely used for their slow releasing fluoride properties. The greatest amount of fluoride release is 24 hours after placement, and continues in lessening degrees over time.¹⁶ GI sealants are classified as low and high viscosity.¹³ Many clinicians prefer GI because success in retention is not dependent on a dry field. “Moisture-friendly” GI sealants are easy and quick to place.¹³ When resins are combined with GI, they are called resin-modified glass ionomers (RMGI). The resin composite component makes RMGI even less sensitive to moisture and provide a longer working time.¹³

Polyacid-modified resin sealants, also known as compomers, combine the properties of resin-based sealants with the fluoride-releasing and adhesive properties of GI sealants.^7,13 Polyacid-modified resin sealants adhere easily to the enamel and are less water-soluble.¹³ They are also not highly technique sensitive, making them easier to apply in young and uncooperative patient populations.¹³

CHOOSING THE MOST APPROPRIATE SEALANT

Systematic reviews have not found any statistical difference in the caries preventive effects among all sealant materials; however, RBS and resin-based GI sealants had a greater retention rate over time than GI sealants alone.^7,8,13 Because one material cannot be deemed superior over another, clinicians need to find which material works best for them based on the clinical environment and the age and cooperation level of the patient. Furthermore, using a material the clinician feels most comfortable with will aid in the success of sealant placement and retention, as the procedure can be technique sensitive. Successful placement relies on optimal isolation (with some products), clean tooth surface, appropriate etching and/or bonding procedures, and the use of four-handed dentistry. 

IMPORTANCE OF SEALANT EDUCATION

A 2015 survey of 3,350 participants age 18 and older was recently analyzed to determine adult and parent knowledge of dental sealants.¹⁷ The study concluded that 46.3% of adults and 55% of parents knew about sealants. Sealant knowledge was highest among those whose income was greater than 200% of the federal poverty level and those with more than a high school diploma. 

A 2020 Indian study found that while 71% of parents understood the importance of sealants as a preventive practice, only 34% followed through with sealant placement for their children.¹⁸ Both studies indicate if parents, especially those of low socioeconomic status, have a better understanding and overall knowledge of preventive dental sealants, sealant placement may increase, resulting in a reduction in caries prevalence. More emphasis must be placed on prevention education so parents understand and value the overwhelming benefits of the monetary cost of a sealant. On average, the cost for a dental sealant can range anywhere from $30 to $60 while the cost of a one-surface filling ranges from $115 to $180. A better understanding of the disparities in sealant knowledge can help clinicians cultivate more effective community oral health preventive education programs as well. 

CONCLUSIONS

Dental caries continue to plague children in the US, causing unnecessary mouth pain, missed school days, and an overall decrease in quality of life.¹⁹ While sealants are a highly effective preventive treatment for occlusal surfaces, they are still greatly underused.^7,8 Dental hygienists must choose materials whose properties allow them to have greatest success in placement. Vast efforts must be made to educate parents about sealants and to strongly encourage them to proceed with sealant placement to decrease future caries development. 

REFERENCES

1. Edelstein BL, The dental caries pandemic and disparities problem. BMC Oral Health. 2006;6:1.
2. United States Centers for Diseases Control and Prevention. Prevalence of Total and Untreated Dental Caries Among Youth: United States, 2015–2016. Available at: cdc.gov/​nchs/​products/​databriefs/​db307.htm. Accessed January 16, 2021.
3. Marinho VC, Worthington HV, Walsh T. Fluoride gels for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2015;15:CD002280.
4. American Dental Association. Fluoridation Facts. Available at: ada.org/​~/​media/​ADA/​Files/​Fluoridation_​Facts.pdf?la=en. Accessed January 16, 2021.
5. US Centers for Diseases Control and Prevention. Water and Fluoridation Data and Statistics. Available at: cdc.gov/​fluoridation/​statistics/​index.htm. Accessed January 16, 2021.
6. Family L, Zheng G, Cabezas M, et al. Reasons why low-income people in urban areas do not drink tap water. J Am Dent Assoc. 2019;150:503–513.
7. Slayton RL, Urquhart O, Araujo M, et al. Evidence-based clinical practice guideline on nonrestorative treatments for carious lesions: a report from the American Dental Association. J Am Dent Assoc. 2018;149:837–849.
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11. Splieth C, Förster M, Meyer G. Additional caries protection by sealing permanent first molars compared to fluoride varnish applications in children with low caries prevalence: a 2-year results. Eur J Paediatr Dent. 2001;2;133–137.
12. Muñoz-Sandoval C, Gambetta-Tessini K, Giacaman R. Microcavitated (ICDAS 3) carious lesion arrest with resin or glass ionomer sealants in first permanent molars: a randomized controlled trial. J Dent. 2019;88;103163. 
13. Naaman R, El-Housseiny AA, Alamoudi N. The use of pit and fissure sealants—a literature review. Dent J. 2017;5:1–19.
14. Paula AB, Toste D, Marinho A, et al. Once resin composites and dental sealants release bisphenol-a, how might this affect our clinical management?-A systematic review. Int J Environ Res Public Health. 2019;9;16. 
15. Walters MA, Sleeper LJ. Benefits and risks of dental sealants. Dimensions of Dental Hygiene. 2018;16(2);21–23.
16. Rolim FG, de Araújo Lima AD, Lima Campos IC, et al. Fluoride release of fresh and aged glass ionomer cements after recharging with high-fluoride dentifrice. Int J Dent. 2019;10;9785364.
17. Junger ML, Griffin SO, Lesaja S, et al. Awareness among US adults of dental sealants for caries prevention. Prev Chronic Dis. 2019;14;16:E29.
18. Lakshmanan L, Gurunathan D. Parents’ knowledge, attitude, and practice regarding the pit and fissure sealant therapy. J Family Med Prim Care. 2020;9:385–389.
19. Souza JGS, Souza SE, Noronha MD, et al. Impact of untreated dental caries on the daily activities of children. J Public Health Dent. 2018;78:197–202.

From Dimensions of Dental Hygiene. February 2021;19(2):22-24.