Editor's note: Originally published April 1, 2020. Updated April 2023.
Each morning, I open our office’s morning huddle with a word of inspiration typically centered on a theme. At the start of the new year, our theme for the week was “goal setting.” One of the quotes I used was by Warren Buffett, “I do know that when I am 60, I should be attempting to achieve different personal goals than those which had priority at age 20.” While personal goals may differ at age 20 compared to age 60, do preventive goals? In my practice, whether you are 5 years old or 95, we provide a tailored preventive program for our patients' oral health.
After spending years in a federal health-care system, I argue that one of our greatest downfalls as oral health prevention experts is unknowingly making assumptions that adults are healthier than children and that their risk for caries is less. You might be thinking right now, “I do not assume anything. I look at each patient and provide care based on their risk for disease.” But as I have reflected on my own experience, I can’t help but wonder if there are certain habits that dentists have formed based on the influence of education, experience, or insurance coverage trends that result in fewer clinical prevention efforts in adults.
Reflect on the following questions:
• How often do you review oral hygiene instruction with your adult patients?
• How often do you talk with adults about nutrition and daily habits?
• How often do you recommend innovative preventive products that contain xylitol or other chemotherapeutics?
• How often do you set SMART goals (specific, measureable, actionable, realistic, time-bound) with adults?
• How often do you use in-office or at-home fluoride products with adults or check the type of water they consume?
• How often do you place sealants in adults?
Now, ask the same questions, and answer them as if you were referring to a 5-year-old patient. Are your answers the same or different? Our mouths are exposed to far more cariogenic bombs as adults than we had as children. Think of an adult patient who starts the day with a venti caramel macchiato with extra whip from Starbucks, has a sugar-laden yogurt and granola bar for a quick breakfast at their desk, a diet Coke for a little midmorning pick-me-up, then a piece of cake for a coworker’s birthday lunch ... and it’s only one o’clock. If this were a 6-year-old, you would have them on the highest CAMBRA protocol, recommend frequent recare appointments for application of in-office preventive agents, and coach the whole family to make changes in their daily nutritional habits.
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In my practice, after completing a caries risk assessment, we coach patients to reduce their risk factors. For example, we offer multiple options so that they have an oral hygiene routine that is unique and tailored to their needs, place them on a risk-specific recare protocol, and give a preventive treatment plan that includes in-office treatments. While we could tackle many aspects of adult prevention, in this article I will simply review the research on using pit-and-fissure sealants to prevent or arrest occlusal caries in permanent dentition.
Scientific evidence for sealants
Do we have evidence for sealing adult molars to prevent caries incidence or arrest? Yes, we do. In 2008, a systematic review was published in the Journal of Dental Research supporting the clinical practice of using resin-based or glass ionomer sealants to seal noncavitated carious lesions and lesions where the caries status is challenging to determine.1 In 2013, the Cochrane Library published a systematic review that supported sealing permanent molars with either resin-based or glass ionomer sealant to prevent the development of new caries on occlusal surfaces of permanent teeth.2 Then, in 2018, one of the most influential systematic reviews and clinical practice guidelines to be released from the American Dental Association Center for Evidence-Based Dentistry was titled, “Evidence-based clinical practice guideline on nonrestorative treatments for carious lesions.”3 This systematic review/clinical practice guideline supports the use of pit-and-fissure sealants by themselves or in conjunction with fluoride varnish to arrest/prevent noncavitated occlusal caries lesions.
Many young adults, ages 18–35, present to my office with sealants that have avulsed. Should we replace these sealants to continue to prevent occlusal caries or to arrest noncavitated occlusal lesions? Yes, and here’s why.
There are few young adults who have more protective factors than risk factors. Young adults often have nutritional habits that include high caries risk (e.g., frequent snacking and consumption of carbohydrate-laden foods) combined with adjusting to life as an adult, aka adulting, while working to figure out their own oral hygiene routines. Their routines often include forgetting to brush their teeth before falling asleep and drinking lots of caffeinated beverages. These beverages often contain sugar as well as acids (hello, college life and your first job). The list is too numerous to mention, but we must include alcoholic as well as nonalcoholic beverages. As we discussed, sealants are indicated to prevent caries in permanent teeth and are a great option for adult patients with these described habits.
Give sealants a break!
Just because a sealant avulses doesn’t mean that the tooth can’t or shouldn’t be sealed again. We need to move away from the idea that it is inconvenient or unnecessary to replace sealants in adults, or that sealing a tooth won’t be covered by insurance, so we don’t need to recommend it. When I give treatment plans to my patients, my mantra is, “Give everyone all their options.” No matter the patient’s financial situation, insurance coverage, or current habits, I take time to discuss the choices in regard to finances, time constraints, and personal oral care habits. I use this opportunity to educate my patients about the benefits, risks, and alternatives for different treatment options. To date, I haven’t had an adult patient refuse a sealant. Instead, they send their friends to us for sealants too!
So, give sealants a break! Just because a sealant fails or wears out doesn’t mean it didn’t serve its purpose for a few years. As clinicians, research has planted an idea in our minds that sealants fail because they are not retained indefinitely. First, that is an unrealistic expectation, and second, a sealant’s retention factor alone does not determine its success or failure. If caries are present or allowed to progress, sealants will fail. This outcome can be prevented by determining whether or not a sealant is retained.
In a high-caries-risk patient, a glass ionomer sealant may have to work incredibly hard for two years to prevent caries in a pool of saliva that is constantly acidic and/or frequently exposed to sticky foods. Why are we shaming that sealant for dissolving after two years or avulsing? Instead, we should be applauding the sealant for preventing the start of a chronic disease.
I argue that we all need to increase our preventive protocol and support for adults across the United States. As a health-care system, we can fail adult patients if we do not diagnose, treatment plan, and reimburse for sealants throughout their lifetime. Many consumers know the value in their oral health and expect more. Let’s give it to them.
References
1. Griffin SO, Oong E, Kohn W, Vidakovic B, Gooch BF. The effectiveness of sealants in managing caries lesions. J Dent Res. 2008;87(2):169-174. doi:10.1177/154405910808700211
2. Ahovuo-Saloranta A, Forss H, Walsh T, et al. Sealants for preventing dental decay in the permanent teeth. Cochrane Database Syst Rev. 2013;(3):CD001830. doi:10.1002/14651858.CD001830.pub4
3. Slayton RL, Urquhart O, Araujo MWB, et al. Evidence-based clinical practice guideline on nonrestorative treatments for carious lesions: A report from the American Dental Association. J Am Dent Assoc. 2018;149(10):837-849.e19. doi:10.1016/j.adaj.2018.07.002
