Use of Pit-and-Fissure Sealants

Board takeaway

Seal sound or noncavitated occlusal pits and fissures in children and adolescents to prevent new lesions and inhibit progression of initial lesions.

Identify the lesion and treatment scope

• Caries reflects a biofilm ecological shift with repeated fermentable-carbohydrate exposure and imbalance between mineral loss and repair.
• A noncavitated lesion has altered color, gloss, or surface character from demineralization without macroscopic surface breakdown. Arrest may leave a visible sign of previous disease.
• Primary prevention: seal susceptible grooves before caries develops. Secondary prevention: seal initial occlusal lesions to inhibit progression.
• These recommendations address sound and noncavitated molar surfaces; they do not establish a sealant-only treatment recommendation for cavitated lesions.
• Use sealants within comprehensive caries management and discuss benefits and uncertainty with the child/parent.
• Historical NHANES 2011–2012 data showed increasing caries burden with age and uneven sealant access.
  • Occlusal caries declined less than smooth-surface caries; topical fluoride may protect smooth surfaces more effectively than pits and fissures.
  • These are historical observations, not current prevalence estimates.

Decide at the tooth surface

• First establish that the surface is sound or noncavitated; stain alone neither proves cavitation nor excludes a sealant.
• Then assess fissure anatomy, caries risk, eruption, and moisture control.
• Choose a material that can be placed correctly, explain the benefit and retention tradeoff, and reassess at subsequent examinations.

The strong recommendation supports sealing eligible molar surfaces; it does not require drilling every stained fissure, establish a cavitated-lesion protocol, or eliminate the need for fluoride and daily disease control.

Sealants versus no sealant

• Nine randomized trials informed the principal comparison. For sound permanent-molar surfaces, the 2–3-year estimate was odds ratio (OR) 0.24 (95% confidence interval [CI] 0.19–0.30), reported by the guideline as a 76% reduction in incidence.
• At an assumed 30% baseline caries prevalence, the model estimated 207 fewer lesions per 1,000 applications. Absolute benefit depends on baseline risk.
• A mixed population of sound and noncavitated surfaces also showed benefit: OR 0.25 at 2–3 years. Observational evidence supported sealing initial lesions.
• Moderate certainty reflects study-design concerns, including unclear randomization/allocation concealment.
• Sealing permanent molars can delay or prevent invasive restoration and appears especially cost-effective with previous caries experience.
• No adult trials were identified. Similar benefit might extend to adults, especially with recent caries, but this is an extrapolation without a definitive adult recommendation.

Sealants versus fluoride varnish

• Three randomized trials suggested benefit for sound permanent-molar occlusal surfaces at 2–3 years: OR 0.27 (95% CI 0.11–0.69).
• At 30% assumed baseline prevalence, the estimate was 196 fewer lesions per 1,000 applications.
• In the mixed sound/noncavitated population, the difference was not statistically significant: OR 0.66, CI 0.30–1.44.
• The panel nevertheless conditionally suggests sealants over varnish for the specified molar surfaces in children/adolescents. Low certainty reflects bias and inconsistent results.
• This comparison concerns occlusal pits and fissures; continue other appropriate preventive measures. No adult comparative data were identified.

Materials: know the options

• Resin-based: UDMA or bis-GMA monomers; chemical or light polymerization; filled/unfilled and varied opacity/color.
• Glass ionomer (GI): fluoride-releasing cement from an acid–base reaction involving glass powder and aqueous polyacrylic acid.
• Polyacid-modified resin (compomer): combines resin components with GI-related fluoride-release and adhesive properties.
• Resin-modified GI: GI with resin components; similar fluoride release, longer working time, and less water sensitivity than traditional GI.
• Any evaluated material may be used for sound/noncavitated permanent molars in children/adolescents; the material recommendation specifically uses that scope.

Comparative evidence: retention is not caries superiority

• GI versus resin: caries differences were not significant, including the noncavitated subgroup. GI had greater odds of retention loss at 2–3 years: OR 5.06.
• GI versus resin-modified GI: no significant caries difference; GI had greater odds of retention loss: OR 3.21.
• Resin-modified GI versus compomer: neither caries nor retention differences were significant.
• Compomer versus resin: neither caries nor retention differences were significant.
• Overall comparative certainty was very low, largely from bias, imprecision, and sometimes inconsistency. Wide intervals preclude ranking caries protection; absence of significance does not prove equivalence.
• Supplemental profiles include longer follow-up for some comparisons, but long-term head-to-head evidence is sparse or absent.

Placement and follow-up decisions

• Difficult dry isolation—such as incomplete eruption with overlying soft tissue—favors a more hydrophilic material such as GI.
• Reliable dry isolation plus a desire for sustained retention may favor resin.
• Follow each manufacturer's cleaning, isolation, placement, and curing instructions. Resin placement requires acid etching.
• Adhesives, air abrasion, and enameloplasty are mentioned as studied techniques; the guideline does not make them universal prerequisites.
• Monitor retention. More frequent review may be needed for sealants at greater risk of loss; this is inferred from retention data.
• Resealing was poorly reported, so the panel could not use it to guide material selection. No fixed recall interval or resealing schedule is supplied.

Safety

• Some materials raise bisphenol A (BPA) exposure concerns. The reviewed evidence did not support patient harm from the small, transient exposure associated with placement.
• Two randomized trials assessing adverse events reported none; this does not establish zero possible risk.
• Teeth with fully or partially lost sealants were not shown to have greater caries risk than never-sealed teeth. Loss still warrants monitoring rather than assuming continuing protection.

Evidence limits and clinical judgment

• GRADE separates certainty from recommendation strength. Strong recommendations generally apply to most eligible patients; conditional recommendations require closer attention to individual values and circumstances.
• Decisions incorporated benefit/harm balance, certainty, preferences, and resource use. Certainty may decrease for bias, imprecision, inconsistency, indirectness, or publication bias.
• At the 2016 review, the panel identified a need for better chairside/site-specific risk tools, primary-dentition and adult studies, adequately sized material trials, clearer resealing reports, and studies of other noninvasive arrest approaches.
• The 30% and 70% baseline risks are modeling scenarios, not eligibility cutoffs. Mention of silver diamine fluoride is a research priority here, not a treatment recommendation.

Common board traps

Answer aloud

An adolescent has an initial occlusal lesion without surface breakdown. Why seal it?

If the occlusal lesion is noncavitated, sealing can inhibit progression by isolating the susceptible site.

• The guideline strongly favors sealants over no sealant for eligible primary and permanent molar surfaces, with moderate-quality evidence.
• Also address overall caries risk and monitor retention, because placing a sealant does not remove the need for prevention and review.

A partially erupted first molar cannot be kept dry. Which material?

A hydrophilic glass ionomer may be suitable when a partially erupted tooth cannot be kept adequately dry.

• It offers an isolation advantage but has a retention tradeoff.
• Follow the product instructions and monitor the sealant and tooth, then reassess treatment as eruption and isolation improve; this guideline does not establish a universal review interval.

Can varnish replace sealants, and is resin definitively superior?

The guideline conditionally favors sealants over fluoride varnish for occlusal caries prevention, with low certainty and mixed-population limitations.

• It does not establish a definitive material hierarchy.
• Resin may suit a dry site when retention matters, while glass ionomer may suit a moisture-challenged site.
• Varnish and sealants should be selected within the patient's broader preventive plan.