Fluoride Application After Sealant Placement

This is an excellent question that can best be answered using the principles of evidence-based dentistry (EBD) and considering the concept of standard of care. First of all, I am going to make a few assumptions in regard to the patient population and the type of fluoride application (and hope they are correct). The children you are seeing most likely present with moderate to high caries risk, have little access to dental care, and a fluoride varnish is to be applied immediately following sealant placement. The two treatments are most likely done together so all preventive care can be accomplished in one appointment. According to the American Dental Association (ADA), EBD is an approach to oral health care that involves three components: 1) the use of best available evidence, 2) the clinical expertise of the clinician, and 3) the patients needs and preferences. Standard of Care is defined as the level of care that a reasonably prudent practitioner would have provided under a certain set of circumstances (Graskemper, J., 2004). 

In this clinical situation I believe that all three components of EBD and the concept of standard of care has been fulfilled in order to support fluoride varnish application immediately following sealant placement in this population group. 

Best Available Evidence

A large quantity of evidence to support professional fluoride application for the prevention of smooth surfacecaries and the placement of sealants for the prevention of pit and fissure caries exists. An area of concern in the past has been the use of professional fluoride prior to sealant application. The latest data indicate that sealant bond strength is not compromised and, in some cases, is even more retentive (El-Housseiny, A.A., 2005). The question of subsequent fluoride treatments on sealants has been raised, but there are no data to support one fluoride agent over another in terms of compromising the function and longevity of the sealant. Therefore, no contraindications to post-fluoride application could be found in the literature. 

Clinical Expertise

The clinical expertise of the clinician in this case considers the caries risk of the patient along with other information to fulfill the second component of EBD. If the child is at a moderate or high caries risk a professional fluoride application will benefit the patient, and if a child at low caries risk a fluoride application may be of benefit. 

Patients Needs and Preferences

The third component of EBD considers the patients needs and wants in regard to having both procedures. If the parents want these procedures and the child needs them the third component is fulfilled. 

Since there is not always direct evidence to support the particular clinical situation it is important to use the second and third components of EBD to make clinical decisions. Lastly, I believe that the clinical procedures suggested would meet the definition of standard of care. After consulting with many colleagues they have told me that they place fluoride varnish immediately after sealant placement for patients that are unlikely to return for an additional appointment and I have learned that a community oral health program in my state provides both services at one appointment. I also spoke with the chairperson of the Pediatric Dentistry Department at the University of Detroit Mercy and her response was that there is no question in regard to doing a fluoride varnish after sealant application, it is done often.

Please refer to the American Dental Association website Center for Evidence-based Dentistry that contains two helpful papers that provide clinical recommendations titled, Professionally applied topical fluoride: Evidence-based clinical recommendations and Evidence-based Clinical Recommendations for the Use of Pit and Fissure Sealants. The website states that the ADA Clinical Recommendations do not constitute standards of care but instead are a useful tool that can be applied in making evidence-based treatment decisions. The clinical recommendations in these two publications do not specifically address the two procedures in the same appointment, but again neither one of the clinical recommendations include evidence to contraindicate a fluoride application after sealant placement. 

ADA Center for Evidence-based Dentistry http://ebd.ada.org/ClinicalRecommendations.aspx