Placing quality sealants that last is a challenge for the average general practice! Whether placement is performed by a hygienist , an assistant ,or dentist , here are the best practices for placement of a quality sealant that lasts.
Isolation
Isolation is critical to sealant longevity. While a rubber dam is the gold standard , you may consider using an isovac or isolite by Zyris . Hygienists are able to work alone with a RD or Isolite . I absolutely loved the isolite for all my operative procedures . Placement is fast, and provides excellent isolation and visibility. I loved not having to contend with the tongue. Most patients tolerate it well . For those who don’t , go with the RD . Cotton rolls are the next option.
Give your hygienist an assistant to help with keeping the field dry.
Clean the tooth
It is essential to clean the tooth. You can use pumice with a cup or brush. An air abrasion unit like the one from Danville works great and is very affordable . A cavitron prophy jet works well too . Remember that the sodium bicarbonate is a base so you will have to etch 20 sec to neutralize, rinse and then etch a second time.
Bonding Agent : The Secret Sauce
After drying :the secret to a long lasting sealant is the placement of an adhesive bonding agent prior to the application of the sealant . A universal bonding agent like scotchbond works well. Any bonding agent will work fine . A bonding agent draws the resin down into the enamel rods. There are many sealants on the market but make sure it is resin based, not a glass ionomer. Glass ionomer sealants are not retained as well as the resin sealants . You may place white or clear sealants . The advantage of a clear sealant comes into play if you are sealing in caries. This allows you to effectively monitor any caries progression .
The Dilemma when sealing over decay
I am aware that sealing in caries is being taught in dental schools . I am not a fan!! Dr. Gordon Christensen has written and lectured and shared his views. He does not recommend this and I follow Gordon. Remember that the bacteria under a sealant can become facultative and take off. Try explaining to a parent why their child has caries into the pulp after having sealants placed. I urge you to read the research on cariology conducted by Rella Christensen and the TRAC team. The article Dental Caries 2018: New Insights published Nov 2018 in dental CEtoday.com and featured in Dentistry Today will enlighten you. It shares why the practice of sealing in decay ,or allowing caries to remain under a restoration is a recipe for disaster! I attended an AGD lecture not long ago and the speaker, a pediatric dentist ,was touting the sealing in of decay and several GP’s in the audience expressed their disagreement and stated that the endodontist they referred to, saw a lot of patients with caries under sealants that progressed into the pulp. My professional experience tells me ; Don’t do it!
Review
Isolate- Clean tooth- Etch- Rinse- Dry- Bonding resin- Place sealant- Light cure.
Light Cure
The light curing can be done all at once . There are great lights available. Make sure they are of the adequate wavelength spectrum to effectively polymerize the material. Use a large diameter tip and hold it perpendicular and close to the occlusal surface. Light tips should be examined and free of any cured composite . Make sure you test for adequate output with a radiometer and ALWAYS over cure . My advice is to always over cure from different angles with all your restorative dentistry to ensure adequate polymerization. There is an epidemic of poorly cured composite restorations leading to leaking and subsequent restoration failure.
The Absolute Best Service
The bedrock of our profession is prevention and there is no better service than providing sealants to your patients. In my practice we routinely sealed all deciduous molars and all permanent molars. Those patients with a moderate to high risk caries assessment were treatment planned for sealants on their premolars as well. Deep cingulums of maxillary laterals as well as buccal pits on mandibular molars are good candidates for sealing too. Insurance typically covers permanent molars at 100%. However , when educated , parents readily accept this service regardless of insurance coverage. Make sure you inform before you perform and let parents know the fees up front ! No Surprises !
My Case presentation, Sales pitch
I start by telling the parent that the sealant is the absolute best service available in dentistry . It is conservative. No drilling! No needles! No anesthetic! My hygienist can place them . Sealants help to prevent decay in the deep grooves on the chewing surfaces of back teeth. Food particles get down deep into the grooves. The bristles of the tooth brush are too large to clean those grooves. Sealants are a plastic coating that prevent the jellybean and oreo cookie from getting into the groove. I go on to say that sealants secrete a fluoride that for the life of the sealant bathes all tooth surfaces. In fact ,studies show that kids with sealants have less decay in between the teeth and on other surfaces .Speak on the level of your patients. Don’t say interproximal . Patients don’t know what that is. I tell the parents that I routinely seal all baby molars . They will typically get one application, as those teeth will be eventually lost and replaced by permanent molars. I tell them that I seal all permanent molars and that insurance typically will cover them at 100%. After this , parents are sold. It’s now time to discuss fees and manage expectations!
Manage expectations ! Inform before you perform
You should have informed consent for sealants as well as for all procedures . It is critical to manage patient and or parent expectations . Document ! It will keep you out of trouble. There will be someone question you in your career ! Take intraoral photos and document your findings. Make sure you have a caries risk assessment today and always record a diagnosis . Practice good communication with your patients and parents. Communication is the key.
How long do they Last?
I would always tell parents the industry average for sealant longevity is 3 years .However ,in my experience, and in my practice they are lasting 5-8 years . I tell the parents that sealants will wear down over time and with extreme biting pressure they may pop off. I tell them that if your child consumes a lot of soda and sports drinks the acidity will negatively impact sealant longevity. I then tell the parent that if the child doesn’t brush their teeth they can get decay at the sealant tooth interface , where the sealant meets the tooth. I gave a 3 year warranty. If the sealant was lost within a 3 year period I would replace it for free. The patient had to be on a regular 6 month recall. Parents appreciated that.
Discussing Fees
I routinely quoted the sealant fee per tooth. Then I would give the total for all teeth treated . Be sure to get a signature on the treatment plan. When doing more than 4 teeth , simply send it to the insurance company for predetermination . I can assure you , if you or your staff go too fast and provide a bunch of sealants without mom understanding everything you stand to lose them. Parents are often overwhelmed in the operatory during the case presentation . You or your staff person may be talking fast and the parent or patient isn’t listening.They know they should get the treatment for their child but aren’t fully understanding the cost. If you perform the treatment the same day, mom may get home and have buyer’s remorse or discuss treatment with her spouse who only sees the dollars going out. They didn’t have the benefit of hearing the case presentation. Develop good people skills . LISTEN to and READ your patient/ parent ! Trust me on this one ! Go slow and you’ll be good. When in doubt send a predetermination to insurance.
The most successful dental practices are great at communication! Develop scripts from this post for your staff to use. This verbiage works!
The reality is that many general practices rarely offer sealants. I believe it’s because the dentist places little value on this service. They have more than enough treatment to do . I know the fee is minimal when compared to other restorative care but shouldn’t we, as a profession , promote preventive services no matter the cost? It’s the right thing to do.
Sealants are a great service and can be a profit center within your hygiene department. The most profitable practices place the most sealants. It’s great for the patient and the practice bottom line. A win win!
I hope you have found this post helpful and of some value.