Individual assessment. Assessment of a person’s risk for dental caries relies on a number of factors. These factors could include caries history, preventive practices, nutritional habits and medical conditions (Box, "General Risk Factors for Caries").^2,3

Caries risk is not stagnant in a patient and can vary from one point of time in his or her life to another. Such variation in susceptibility requires ongoing monitoring by the oral health care professional, since changes in health status, use of medications and other lifetime events can increase risk.⁴

Based on the clinical evaluation and information derived from a patient’s medical and dental history, he or she can be classified as being at low, moderate or high risk (Box, "Factors in Low, Moderate and High Caries Risk Assessment").^5,6 In addition, inadequately restored surfaces, poor oral hygiene, exposed root surfaces, orthodontic treatment and elevated Streptococcus mutans levels could be factors.⁵

Evidence is suggesting that caries in the primary dentition increases a child’s risk of caries in his or her permanent dentition.

Tooth surface assessment. It is well-documented that pit and fissure configuration can be a significant risk factor for occlusal caries.⁹ Pits and fissures compose only 12.5 percent of tooth surfaces, yet they account for 88 percent of caries in children.¹⁰ Deep pits and fissures that are not easily cleaned can harbor bacteria that break down the enamel surface. Permanent molars have the most susceptible pits and fissures. Premolar teeth are less susceptible, but in some patients, maxillary incisors with fissured or pitted surfaces may also be at risk.

The professional dental community seems reticent to include sealants in a preventive oral health program.

	INDICATIONS FOR SEALANT USE

TOP ABSTRACT INDICATIONS FOR SEALANT USE THE ROLE OF SEALANTS... CONCLUSION REFERENCES

 
The above discussion of risk assessment indicates that caries is bacteria- and host-related, not age-dependent. Therefore, preventive measures, such as sealants, to target those at risk should not be based on age.

Although sealant use is strongly advocated by the ADA and several oral healthcare agencies, sealant application remains low.¹¹ Between 1988 and 1991, only 18.5 percent of U.S. school-aged children received sealants; 23 percent of nonminority children had at least one sealed permanent tooth, while only 7 percent of minority children did.¹⁰ A goal set by the U.S. Public Health Service for the year 2000, outlined in their program Healthy People 2000, was for 50 percent of children aged 8 and 14 to have one or more sealed permanent molars.¹² Recent data show that 23 percent of children in grades 2 and 3 and 20 percent of children in grades 8 and 9 have their first molars sealed.¹³ Clearly, the goal of Healthy People 2000 will not be met. Healthy People 2010 has reaffirmed this goal: 50 percent of children aged 8 and 14 should have sealants on one or more permanent teeth.¹⁴ This discrepancy in recommended usage of sealants and the lack of application indicates a low level of awareness in the general public. Among the populace, the benefits of sealants for disease prevention appear to be unknown. Further, the professional dental community seems reticent to include sealants in a preventive oral health program, even though evidence in the literature supports their efficacy.

Numerous reasons for lack of sealant use by the dental community have been cited. They include the misconceptions that sealants seal in existing decay, sealants are easily lost, patients prefer other restoratives, patients do not want the initial expense and sealant effectiveness is not proven.¹⁵ Following is a brief review to support sealant use.

Sealants and incipient lesions. Numerous studies have shown that bacteria become nonviable and caries does not progress when sealants are applied to incipient lesions.^16–18 It appears that sealant material effectively eliminates the nutrient source for S. mutans, thus changing a lesion from caries-active to caries-inactive.¹⁹ To ensure an effective seal, careful technique when applying sealants is needed, leaving no open margins. In addition, ongoing assessment of margins to test intactness is important.

Sealant retention. To be effective, sealants must remain in place and completely cover pits and fissures. Two factors most likely to affect retention are proper application and the tooth’s eruption status.^20,21 While sealant placement is fairly uncomplicated, the manufacturers’ procedures must be followed. Regarding eruption status, it has been shown that sealants placed early in eruption are far more likely to need replacement. A study by Dennison and colleagues²² reported that when an operculum existed over the distal marginal ridge of molars, the sealant replacement rate was 54 percent. In contrast, the replacement rate was 0 percent for a selected sample of sealants placed at later eruption stages over a five-year period.²⁴ This creates a dilemma for the practitioner, however, as some permanent molars erupt with fissures that seem at risk of decay. Since they appear at-risk early in the eruption stage, the clinician may opt to seal such surfaces, knowing that replacement may be inevitable.

Sealant efficacy. Simonsen conducted the longest clinical study to date on sealant retention and effectiveness.²³ In children who received a single sealant application, 74 percent of the pit and fissure surfaces of permanent first molars were caries-free after 15 years.²³

Over the past 20 years, numerous studies have shown the effectiveness of sealants. Moreover, the literature suggests that occlusal caries susceptibility remains throughout life.²⁴ Therefore, lifelong, ongoing risk assessment of the patient is needed to determine when sealant use is appropriate.

Sealant cost-effectiveness. Limited studies have been conducted to determine the cost-effectiveness of sealants. However, in a 1992 study by Kuthy,²⁵ dental insurance claims for over 1.3 million children were reviewed over a three-year period. This investigation determined that the average one-surface restoration charge was more than double the average sealant charge.²⁵ An additional consideration, though, is that sealants are rarely retained completely over the tooth’s lifetime and must be reapplied. Therefore, it is important to place sealants using the community, individual, tooth and tooth-surface risk assessment approach. Furthermore, the potential reduction of future expensive restorative procedures by using sealants as preventive measures is an important (although difficult to estimate) consideration.

	THE ROLE OF SEALANTS IN PREVENTIVE DENTAL PRACTICE

TOP ABSTRACT INDICATIONS FOR SEALANT USE THE ROLE OF SEALANTS... CONCLUSION REFERENCES

 
Conservative oral health promotion efforts continue to replace more drastic disease-intervening concepts in dentistry. In this context, the role of sealants is clear.²⁶ Sealants are highly effective in preventing pit and fissure caries. Sealants may be placed with confidence on sound teeth, as well as on teeth with incipient caries activity. They can be provided without anesthesia and without cutting healthy tooth structure. Sealants are esthetically appropriate and relatively inexpensive compared to alternative clinical procedures, and they can be reapplied at any time without removing tooth structure.

Sealants are an essential component of a modern, science-based, prevention-oriented practice.

Sealants prevent disease rather than treat its sequelae. For this and many other reasons, sealants are an essential component of a modern, science-based, prevention-oriented practice.

	CONCLUSION

TOP ABSTRACT INDICATIONS FOR SEALANT USE THE ROLE OF SEALANTS... CONCLUSION REFERENCES

 
Assessing risk for disease development is an important component of any disease prevention program. Risk susceptibility can be determined on a variety of levels, including community, individual, tooth and tooth surface. Since dental caries is a bacteria-dependent, multifactorial disease, preventive measures such as sealants, can be implemented once those at risk are identified. Diagnostic tests and preventive therapies will be critical in the dental practice of the future, where health and wellness will be the primary goals.