by Tammy L. Carullo, RDH, PC, PS
As a dental hygienist, you know that sealants are thin, plastic coatings that seal the pits, fissures, and crevices that exist in permanent posterior teeth. Sealants act as a physical barrier to prevent oral bacteria from collecting and creating the acid environment that allows tooth decay to develop. Wow, what a mouthful!
But when was the last time you updated your skills and knowledge in the area of sealants? Have you ever been educated in sealant application?
It's not a silly question. Some veteran hygienists were not adequately educated in the application of sealants, and they often find themselves in unfamiliar territory. While the concept of sealants is pretty much consistent with that of education in hygiene schools 10-plus years ago, some innovative materials and new information could prove beneficial when treating your next patient with sealants. For those of you who would like to break up the monotony of your day, or perhaps avoid burnout from a grueling schedule of perio patients, sealants are a great source for expanding your repertoire, as well as enhancing productivity.
The first thing that generally comes to mind when educating patients about sealants is that there is no pain involved. In addition, the cost of preventing tooth decay by placing sealants is much less than treating even a small one-surface restoration. While it's unfortunate that tooth decay in the United States is still prevalent, the incidence among children has decreased dramatically. Much of the credit is due to the widespread application of sealants combined with preventive fluoride.
Many sealant products contain fluoride within the sealant material itself. While research to develop a vaccine against dental caries continues, it is important to guard our patients against decay with the combined use of dental sealants and fluoride.
'What are dental sealants,' asked the patient
You may reply, "Dental sealants are thin, plastic coatings applied to the chewing surfaces of the back teeth to prevent decay in children and adolescents." This is a very common approach to educating patients about the basic role of sealants. While it is correct that most tooth decay in children and adolescents occurs on the chewing surfaces of these back molars, it is also correct in stating that most tooth decay in adults also occurs in these areas. This is because molars have irregular surfaces with pits and grooves that tend to trap food and bacterial debris. Sealants flow into and coat these pits and grooves so that bacteria cannot multiply and cause decay.
We know this information, and we know the data that supports the need for sealants. But we tend to draw the line at the miraculous age of 14. The age tends to be dictated by insurance carriers, and dental hygienists and dental practices do not commonly apply sealants on adult patients. However, could they not benefit from this highly preventive service as well? There is no disputing that the natural pits and fissures that are found on the occlusal surfaces of molar and premolar teeth in children and adolescents also exist in adulthood.
Any intelligent dental professional will point out that insurance companies are not the ones looking out for the patient's health and well-being. Are we surprised that they would not want to cover a preventive service such as "adult sealants?" Does that make the need or benefit from the service any less important? No. The bottom line is that every patient, child, adolescent, adult, and little old lady who does not have decay in these areas would benefit from sealant application. Sealants are purely a preventive measure to ward off the decay process in an area that is typically predisposed to the bacteria believed to create the caries.
The first order of business in regard to sealants is to evaluate who needs them. The second is how you apply them. For many RDH readers, this portion of this article will be a "review." However, my approach to success in continuing education and clinical development is "learn the new, but first master the old." Continuing education is more than simply learning the "new info" out there. CE is a great opportunity for brushing up on "old" information. For some of the practicing hygienists who may not have been formally taught the ins and outs of sealant application, this one's for you.
A primer on the application process
After you have determined who will be receiving sealants, you are faced with the dilemma of the best way to apply sealants so that they will not fall off. Yes, one of the most frustrating aspects of sealants is their seeming inability to stay on.
Applying sealants is quite simple. First I would like to dispense with the traditional protocol of using pumice to clean the tooth surface. Still being taught in hygiene schools across this country, this can sometimes impede adhesion of the sealant. However, you do need a clean surface.
My 12 steps to successful applications of sealants are as follows:
- Clean the tooth surface with a dry prophy brush to remove debris.
- Place a Dri-Angle between buccal/facial of tooth surfaces and cheek, and a cotton roll on lingual side.
- Give the patient the saliva ejector, asking him to help maintain a dry field.
- Dry tooth surface with air.
- Apply blue etching gel (it works the best; you can see exactly where it goes).
- Allow the etching gel to stay on the tooth surface for a minimum of 15 seconds.
- Rinse and dry tooth (the tooth will appear chalky when rinsed and dried).
- Apply a new Dri-Angle and cotton roll if needed.
- Dry tooth thoroughly.
- Apply a very thin stream of sealant material.
- Light cure the sealant.
- Check for successful seal.
There's no need to check the bite. It is better for the patient to develop natural wear patterns in the sealants. After the sealant is successfully applied, bacteria cannot reach the pits and grooves, therefore halting the decay process.
There are two schools of thought about sealant application on a tooth with a suspicious or "watch" area. The first thought is that, if a sealant is placed, the bacteria causing the decay will be starved of oxygen, halting any future decay process.
However, there have been cited incidences where sealants were placed in questionable areas. Instead of halting the decay process, the decay spread apically resulting in an endodontic situation. Clearly, the battle lines are drawn here as to which approach is best.
Sealants play an important role in the prevention of tooth decay. However, a total preventive program will include not only sealants, but fluoride, daily brushing and flossing, nutritional counseling to limit high sugar/simple carbohydrate foods, and regular dental visits. This will provide your patients with a well-rounded best-case scenario for improved oral health.
Sealants provide patients with another premier preventive service as well as additional productivity to the dental practice. So, avoid the complacency rut, and maintain your clinical edge with sealants today!
Tammy L. Carullo, RDH, PC, PS, is CEO of Practice by Design, Inc. She is a practice-management consultant and continuing-education instructor. She may be contacted by e-mail at [email protected] or phone (717) 867-5325. For more information about her company, visit www.practicebydesign.com
Some issues of concern: How safe are sealants?
A few studies have found that chemicals from some plastic resins commonly used in dental sealants and composite fillings can filter out from the material and imitate the effects of estrogen. Estrogen is a natural female hormone that promotes estrus and stimulates the development of female secondary sex characteristics. One such study titled "Estrogenicity of resin-based composites and sealants used in dentistry" appeared in the March 3, 1996, edition of Environmental Health Perspectives.
Many questions remain unanswered. For example, it is not clear if the chemicals detected in saliva after sealants were applied actually entered the bloodstream or if they were metabolically broken down by the body. Other studies suggest that the amount of filtered chemicals are very small and dissipate quickly after sealant placement.
The estrogenic effects of the chemicals from dental sealants have yet to be demonstrated in normal human cells. Therefore, the risks are still unclear and unsubstantiated.
Some chemicals used in dental sealants may filter out and have the potential to imitate estrogen; however, the safety of both dental sealants and composite fillings have been monitored for 20-plus years and are continually monitored. More studies are clearly indicated to substantiate concerns surrounding sealants.
Sealants are composed of various resin systems that may include cyanoacrylates, polyurethanes, and BIS-GMA products. The most commonly used products are generally comprised of BIS-GMA and are similar to composite resins used as tooth-colored filling materials.
Many studies have been done during the past 20 years to determine the safety and efficacy of these products. A recent study did raise questions regarding the estrogenic potential of one ingredient found in some sealant products. However, the only current documented adverse effect of dental sealants and their placement is allergic reaction.
Finally, in order to bond with tooth structure, the tooth must be clean. Etching the tooth surface is required. The acid used to etch teeth is usually phosphoric acid. This can be used in varying strengths, but the most common strength is 37 percent.
The acid etch serves several purposes:
- Removes debris from the tooth surface
- Provides better wetting capability of the enamel for the resin
- Selects dissolution of the enamel surface.
Enamel is normally porous, but etching does remove some of the calcium salts to increase microspaces. This allows "tags" of resin to penetrate the enamel for better bonding. If a surface of enamel inadvertently is etched, generally polishing the enamel surface is sufficient to repair this area.