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Howard Speaks

To Seal or Not to Seal?



Howard Farran, DDS,
MBA, MAGD
Publisher,
Dentaltown Magazine 		There is an awesome thread on Dentaltown.com titled “To seal or not to seal.” If you read the thread you will find out that dental sealants are very controversial. Some let their hygienists do them, while others believe it takes two people to place a great sealant. Some dentists believe that the hygienist should concentrate on periodontal disease and let the dentist with an assistant concentrate on adhesive dentistry. Other dentists believe that the pits and fissures need to be cleaned out with a bur or air abrasion unit while others do not. The dentists who clean out the grooves with air abrasion or a bur are reporting that between 10 and 50 percent of the time they are down into dentin and then they bill out an occlusal composite. Bottom line – most sealants are placed poorly.

I e-mailed the first lady of dentistry, Rella Christensen RDH, Ph.D., about dental sealants, and this is what she had to say:

“I think sealants are a great idea. The anatomy of pits and fissures was not designed for western civilization's high sucrose diet. In my opinion, the sealants are not the problem. The problem is the clinical judgments on when and how to use the sealants.

Sealants are difficult and time consuming to place when done correctly, but our renumeration system places them well below Class 1 restorations – which, in my opinion, are actually easier to accomplish.

I wrote an article for DPR's[Dental Products Report] Micro Dentistry Section earlier this year where I outline what I consider a good step-by-step sealant technique. It calls for use of magnification, five percent glutaraldehyde disinfection and SEP adhesive before sealant placement, and monitoring with the same care given a restoration after placement – including fluoride varnish application on margins at regular intervals, once to twice a year. Do you think anyone will adopt such a technique at today's reimbursement? I also stated that the teeth should be sealed as they erupt and clear the soft tissue completely. Do you think anyone would consider sealing two or three teeth and not wait until all four were available at the same time?

Howard, sealing pits and fissures of newly erupted teeth and monitoring those sealants carefully for the rest of the patient's life is a sound preventive procedure. The problem is no one does it that way.”

Then I e-mailed Gordon “The God of Dentistry” Christensen DDS, MSD, Ph.D., and asked for a succinct quote on the status of dental sealants. This is what he said:

"There appears to be a revival trend toward leaving overt dental caries or questionably present caries in occlusal grooves and sealing the lesions in the tooth with conventional pit and fissure sealants. Although that concept may slow dental caries progression for a period of time, it has been my observation that eventually the lesions progress, even to the extent of pulp exposures. A more logical and rational approach is minimally invasive removal of the carious lesions with a tiny bur or diamond or with an air abrasion unit, accomplishing conventional acid etching and placing a small amount of resin-based composite in the tooth preparation. These small resin restorations serve indefinitely, and there is no question that dental caries has been removed. The only disadvantage to the removal of caries is that the tooth structure removal must be done by a dentist, while the conventional sealant can be done by a staff person. If conventional sealants are to be placed properly, they should be placed as soon as the gingival tissues are no longer on the tooth occlusal surface, and that is just a few months after eruption."

The irony of sealants is that most dentists take adhesive dentistry as serious as a heart attack when doing composites, but not when it comes to dental sealants. Most dentists use a rubber dam when doing composites but not when they are doing a sealant. Could a dentist do a posterior composite alone without an assistant? If not, then why do you have your hygienist place sealants without an assistant?

One dilemma is isolation. You cannot have a contaminated field and expect a great bond. Like with all restorative procedures you need a rubber dam or a great dental assistant that can help you keep the operative field clean and noncontaminated.

Another dilemma

What are you bonding to when the pits and fissures are filled with debris and bacteria? Adhesive dentistry is designed to bond to enamel and dentin, not organic muck. Look at the double standard between dental sealants and restorative dentistry. Do you routinely leave decay under your composites? Some have said that if you sealed in the decay it would eventually die and be entombed. But do you really believe that? Do you practice leaving in decay under your brand new composites? I would venture to say you would do this only if you thought it would lead to a pulp exposure and being conservative you want to see if the patient could get by first with just a filling instead of immediately condemning the tooth towards endodontic therapy.

So if you do not leave in decay on your posterior composites then why do you do it routinely with sealants? As mentioned before, when you clean out the pits and fissures, the dentists who clean out the grooves with air abrasion or a bur are reporting between 10 and 50 percent of the time they are down into dentin, and then they do their regular composite technique and bill out an occlusal composite. Then how could you have your hygienist placing sealants if they are not allowed to clean out the grooves with a bur or air abrasion? And if your hygienist bills out a posterior occlusal composite, that would be insurance fraud and you’d get in big trouble with your state board.

I think most everyone can agree that an occlusal composite would last many times longer than a traditional sealant. Your patients who are getting sealants today are going to live another 60 to 80 years! Do you really think those dental sealants are going to last if you do them with your shortcut compromised adhesive dentistry routine unlike your far superior adhesive dentistry routine, which you follow very faithfully with your composite placements?

What about the ongoing practice of going into elementary schools and placing free dental sealants usually paid for by Medicaid? Do you really think you can do adhesive dentistry without an operatory? Without suction? Without all the gadgets we need for doing basic adhesive dentistry? Would these dentists going into elementary schools think they could also do restorative dentistry? Of course they wouldn’t because they know you couldn’t. Once again there is that double standard between adhesive dentistry as applied to dental sealants versus posterior composites!

Just think how serious you are when it comes to root canals. Just think how much continuing education you have taken on adhesive dentistry for your restorations. Then think about why there is this double standard with sealants? You probably have never taken a continuing education course on sealants. You have staff do them without a rubber dam or an assistant and yet you expect them to have total isolation, which is necessary for adhesion. You almost always do all four permanent first molars at the same time, even though one or two of the teeth are only partially erupted and there is still gingival tissue on part of the occlusal surface thus making a great bond impossible. It’s long past time that dentists need to start taking dental sealants as serious as they do with their composite restoration technique and end the double standard.
Dentaltown Magazine
September 2025
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