Monday, August 1, 2011

Decay Under Sealants

Hey hey hey. It’s me. I don't know if you remember, but I traded blog days with Dr. Joyce when I was on vacation. So here I am on Monday. It worked out well because I am working today. By the way, this working on Monday thing stinks, but, I digress.

I have seen a couple of movies that I wanted to tell you about. I saw "Black Swan." Hated it. I saw "Horrible Bosses," like I said. It was very good, but don't see it with the kids (I saw this at the regular theater at regular prices. Wow. We saw the 4:15 showing and for 4 of us with popcorn and drinks, it was $65.) I saw Soul Surfer (at the dollar theater, with 4 kids, popcorn and drinks galore for $19). I saw "American Pyscho" with Christian Bale, and I hated this one too. And yesterday I saw "Thor." This is, by far, the worst Marvel movie so far. I have really liked all the others and this one just wasn't good.

I am almost done with my book on Bonhoeffer. It was 570 pages of histooooooooooorrrrrrrryyyyy… Sorry, I fell asleep for a second there. It was like reading an encyclopedia. There was zero action. No plot. No big ending. Just history. Anyway, next up is Tim Tebow's Through My Eyes.

Okay, topic of the day. I am a big sealant person. I think sealants are the bomb. I think when done well, they are so good at preventing decay. That being said, there are some problems with them. At least with me.

You know I use the Design for Vision 3.5's and I use a headlight (Perioptix - totally recommend them). I see very well. When I do exams, I see through a tooth. Do you all get this? I look at the color of the tooth. I look past the enamel. I am almost looking at the dentin. I get what the color of the enamel is so I want to see what color is coming through the enamel. I am feeling a tooth with an explorer but I almost trust my eyes better than my explorer.

So something that doesn't stick does not always mean there is nothing there. Sometimes, I will go into a tooth that I see an issue with. I still doubt myself sometimes, but almost all the time (I can count on two fingers when I was wrong) there is decay.

Going back to sealants. I am doing an exam, and I see a sealant. First, I am locked out of the tooth. I have no tactile sense on this tooth anymore. All I have is my eyes. But you know what goes on. We see virgin teeth and we want to seal them, as fast as possible. I check to see if I get a stick, and if there isn't any, I am sealing that puppy. What if there is a stained groove but no stick? I seal it. But we all know what that sealed tooth looks like. It looks like there is color coming from the dentin. Hmmmm?

What do I do? Do I start cutting through sealants every time I see color through them? I love sealants, but my assistant feels the opposite. She hates sealants because she sees the disasters. The disasters are the ones with color that I watch. Next thing you know, it is 3 years later and I feel that the color is getting bigger. I cut through the sealant and KA-BOOM, there is so much decay under this thing it is almost a pulp exposure. And it is usually on a 12 year old or something.

I did two today that were exactly this. I didn't watch them, but I saw this girl who was a new patient. The sealants looked great but the color didn't seem right to me. Got in them and HELLO. So this girl who "has never had a cavity before" has two giant fillings in her mouth (that look spectacular, if I don't say so myself).

While I was filling up these big holes I decided to do sealants on her second molars. I checked and checked with an explorer before I did them. We used to go under the assumption that even if there is a bit of decay and you seal over it, the sealant will starve the decay and it won't get any bigger. Sound familiar? I still do buy that, but what can I do but doubt sealants now? I just can't. One of my pediatric dentists does fissurotomies before every sealant. I think this might be a little overboard, but at least he knows before he puts the sealant on. I believe in them. I do them on my kids. But you can bet that I am checking their teeth before I put them on. And nowadays, I check them double after.

Thoughts? Let me know how you do sealants, and on whom. See you Wednesday (Mondays suck).


P.S. I think a rating system comes up at the bottom of the blogs now. (At least it does when I go back to them). Do me a favor and rate the blogs after you read them (email people won't be able to do this). Then I can start to know what you like the best and do blogs that way.


Anonymous said...

Sealants leak, point blank. They are only indicated on those kids who don't brush and have food stuck in their teeth all the time. On the rest of the population sealants are useless. Now fissurotomies with etch, bonding agent, and flowable composites work quiet well. If you think you should not be opening the tooth up with a quarter round bur then the tooth does not need a sealant either. That is my 2 cents.

Anonymous said...

After treating a patient base of primarily children for about two years, I had experienced all of the situations you mentioned.

I do not complete a fissurotomy before every sealant, but every time I see even a bit of stain, which ends up being before almost every sealant/prr.

I do not seal over decay, because too many times children return with part of a sealant missing, which allows leakage, which allows the decay to explode underneath.

Good topic!

Anonymous said...

Hi John great post. i totally agree with you in terms of diagnosing pit and fissure caries. i think a clean,dry,magnified well illuminated view of the tooth is most important and i only use the explorer if im unsure about what i see and really need some tactile feedback.sometimes the explorer sticks simply because of the geometry of the fissure and i find it can be inaccurate.

if its just a stained groove with no color change in the surrounding tooth structure i may or may not seal it depending on my assessment of that patients caries risk and restorative history. med or hi risk = seal, low risk=no seal and thats a judgment i make irrespective of patient age. i dont think every virgin posterior tooth needs to be sealed as soon as it erupts.i think its a waste of time and money in a low risk caries patient. I know what you mean about sealing over stained grooves.the uncertainty is a problem for me so i try and take it all out before sealing.

i use my bitewings a lot to check for decay under existing sealants and so many times it shows up clearly.a couple of times new patients have come to me with sealants that look perfect clinically but have a small radiolucency under them on the guess is the dentist sealed over i am unsure.if its sealed off the caries should arrest and you shouldnt need to take the whole thing i monitor the sealant and the lesion on successive bitewings and if it looks like the sealant is failing or the lesion is increasing in size i get in there straight away.

an annoying problem i have with fissure caries on partially erupted molars is moisture control for my resin sealants so i use gic here and replace it when it breaks down with resin (by which time the tooth has hopefully erupted more so i can do a great sealant).

keep up the good work!

Dr. Andy said...


How do you handle this situation? New patient comes in and parents proudly state that "their kids have never had a cavity." They are proud to state that they've sealed the teeth as recommended by previous DDS. They've seen other dentist in the mean time and "no cavities".

Here you come along and tell them they have decay on all first molars. You are being truthful but you know what the new patient is thinking, "$$$"

Maybe worse is when YOU recommended sealants and the patient still gets decay on the molars. "But you said those sealants were there to prevent cavities".

Dr. Andy

gatordmd said...


Great question and I have to tell you that it happens to me all the time.
Trust is such a huge thing. How do you gain someones trust?
I definitely tread very lightly. I tell them that I understand how this looks and I hate to be the bearer of bad news....
And also it is the intraoral camera. I show them.
I show them during the hygiene appt. Then I show them after I have opened it up so they can see the brown.
Then, of course, I show them the after.

Then I hope it is fan for life.

Anonymous said...

The operative words are "to help prevent cavities". But most people think once a tooth has been worked on it is bullet proof or because they live such a clean living they are bullet proof too.

Anonymous said...

Gordon Christiansen said sealants all fail. He thumbs in a regular (not flowable) composite. I tried this a few times but on a super wet and uncooperative kid it is not so simple. I live a fissurotomy, peroxide cleanse, etch, prime and bond not cured and then adding a sealant.

Anonymous said...

Frankly, I hate sealants. Too many clowns out there do wall-to-wall sealants on every 12 year old that walks in the door. I mean, when's the last time you saw occlusal caries on a lower bi? It's pretty rare. And who's the tard who thought sealing over incipient caries was a good idea? In my practice, a candidate for sealants comes along quite rarely - that erupted molar that has ultra deep but perfectly clean grooves. And I never delegate them out - I always do them in my chair with an assistant. (btw they're $18 here). I think the best trick for sealants though is to let bleach sit on the tooth for 20 seconds before etching. This removes alot of proteinaceous junk, bugs included, from the tooth. You can even the fine foam forming much like you in endo. After you etch you can REALLY see into the grooves well. There's no data on this but this methodology seems sensible. I never do fissurotomies; either a tooth needs a sealant or an occlusal. Taking a bur to a tooth means it is no longer a virgin tooth and thus has now entered the restorative cycle. Try the bleach sealant thing. You'll be surprised. G in BC


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