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Q&A on evidence-based clinical recommendations for sealants

To assist dentists in using the new Evidence-Based Clinical Recommendations for the Use of Pit-and-Fissure Sealants, the ADA has developed a set of questions and answers to aid dentists in interpreting the new guidelines and discussing them with patients.

I've heard of evidence-based dentistry, but what is EBD really?
Evidence-based dentistry is based on three equally important pillars: a dentist's clinical skill and judgment, each individual patient's needs and desires, and high quality evidence. Only when all three are given due consideration in individual patient care is EBD actually being implemented. The third pillar, high quality evidence, is there to inform dentists and patients, but never to mandate a specific course of treatment.

What are evidence-based clinical recommendations?
They are a set of recommendations derived from the current scientific evidence that serve as a tool for dentists to use in addressing specific clinical situations.

Who actually develops these recommendations?
A panel of researchers and practitioners developed the recommendations after conducting an extensive critical assessment of the scientific literature. The results are reviewed by the ADA Council on Scientific Affairs and other ADA agencies.

How could the sealant clinical recommendations change the way I practice dentistry?
The clinical recommendations reach a number of conclusions that support things that dentists have known all along, including that:

  • Dental sealants are effective at preventing dental decay (primary prevention);
  • Both children and adults can benefit from the use of sealants.

Other conclusions may be less familiar to dentists including that:

  • Sealants can stop noncavitated (incipient) lesions from progressing (secondary prevention);
  • In most cases, removing tooth structure before placing a sealant is not recommended.

To be effective, sealants must be applied properly, monitored and replaced when needed.  The evidence shows that retention of sealants is significantly enhanced when a four-handed placement technique is used.

What is the difference between primary and secondary prevention?
Primary prevention is intended to prevent the onset of disease—in this case, using sealants to prevent caries. Secondary prevention is intended to treat a patient who presents early (preclinical) signs of a disease to stop the disease from progressing. As a secondary preventive measure, a sealant is placed on an early, noncavitated lesion to stop it from progressing to a cavitated lesion.

Do the recommendations say anything about using X-rays?
A footnote to the sealant recommendations states that dentists should use recent radiographs, if available, in decision-making, but should not take radiographs for the sole purpose of placing sealants. The ADA/FDA radiographic guidelines include recommendations on prescribing and patient selection.

What is the difference between a "noncavitated" lesion and an "incipient" lesion?
The recommendations use the term "noncavitated," which is defined as pits and fissures in fully erupted teeth that may display discoloration not due to extrinsic staining, developmental opacities or fluorosis, but that exhibit no shadow indicating dental caries. Some dentists use the term "incipient lesion" to describe the same condition.

How can I best explain to my patients that sealing over incipient decay is the most appropriate treatment?
How you communicate with an individual patient depends on that patient's understanding of dental caries. The ADA has published a patient education page, "Dental sealants: Protecting teeth, preventing and halting decay," in the March JADA, which you can remove and use to talk with your patients.

I'm uncomfortable sealing over incipient lesions. Is it wrong to remove the incipient decay prior to sealing the tooth?
Patients rely on their dentists—as members of a science-based profession—to use the best available science to inform their treatment decisions.  Your professional judgment, which is based on your experience and high quality evidence such as the clinical recommendations, together with the patient's needs and desires, determine the appropriate course of action.

I routinely use sealants for children. Should I consider using sealants more frequently on adults?
Yes, the recommendations are clear: sealants are not just for children; adults can benefit too. The evidence supports placing sealants on pits and fissures of an adult's permanent tooth when it's determined that the tooth or the patient is at risk of developing caries. It also supports placing sealants on early (noncavitated) lesions in adults to reduce the percentage of lesions that progress to the dentin.

Will dental benefit plans cover sealants placed on adults?
The dental benefit industry will make decisions about coverage based typically on financial considerations. Additionally, the coverage may vary between benefit plans.

Will benefits be paid for replacement of sealants?
Specific details on coverage, such as replacements, are contained in the benefit plan documents. Since the clinical recommendations point out that sealants are effective in reducing the need for subsequent restorations, the ADA hopes that dental benefit plans may begin to include or increase coverage for sealant replacements.

Where can I go for more information about clinical recommendations on use of pit-and-fissure sealants or evidence-based dentistry in general?
Members are encouraged to call the ADA at the toll-free number, Ext. 2878, visit ADA.org or e-mail science@ada.org.