|Year : 2016 | Volume
| Issue : 2 | Page : 92-94
Sealing versus Nonsealing: Cost-benefit analysis
Anshula N Deshpande, Rameshwari Yashpalsinh Raol, Urvashi Sudani, Neelam Joshi, Neha Pradhan
Department of Pedodontics and Preventive Dentistry, K. M. Shah Dental College and Hospital, Sumandeep Vidyapeeth, Vadodara, Gujarat, India
|Date of Web Publication||13-Oct-2016|
Rameshwari Yashpalsinh Raol
Tower A1, Sankalp, Sun Milan Apartments, Block No. 104, Waghodiya Road, Vadodara, Gujarat
Source of Support: None, Conflict of Interest: None
Dental caries still remains the second most prevalent disease after common cold, out of which occlusal caries is the most profound one. In India, more than 40% of children are found to be affected by dental caries. Occlusal surfaces of the teeth are most susceptible sites for caries development due to their morphology. They are least benefited from fluoride application. Various efforts have been made by the preventive means to decline the rate of caries, one of which being sealant application. Sealants have come into existence long back since 1971 when first pit and fissure sealant Nuva-Caulk came into existence. There have been piles of literature stating the benefits that arrive from sealing the teeth. However, one crucial point that is being missed most of the times is the cost-effectiveness of the sealant. There are various schools of thoughts, regarding this that is controversial ones. Some of the analysts believe that always sealing may be a bit costlier, but it reduces subsequent dental treatments and hence saves money as well as time. However, some believe that why to unnecessarily seal the teeth in all cases even when the child is not at a risk to develop caries. Hence, we need to foresee both the sides of equation. For best clinical practice and decision-making, we need to have a balance of best evidence, clinical judgment, and the most important, patient needs and preferences.
Keywords: Cost-benefit, dental caries, pit and fissure sealants
|How to cite this article:|
Deshpande AN, Raol RY, Sudani U, Joshi N, Pradhan N. Sealing versus Nonsealing: Cost-benefit analysis. J Oral Res Rev 2016;8:92-4
|How to cite this URL:|
Deshpande AN, Raol RY, Sudani U, Joshi N, Pradhan N. Sealing versus Nonsealing: Cost-benefit analysis. J Oral Res Rev [serial online] 2016 [cited 2019 Jul 16];8:92-4. Available from: http://www.jorr.org/text.asp?2016/8/2/92/192247
| Introduction|| |
Although the rate of caries is declining, it is the second most prevalent chronic infectious disease worldwide.  In India, <40% of children are affected with it. According to the National Oral Health Survey report, caries prevalence in India was 51.9%, 53.8%, and 63.1% at the age of 5, 12, and 15 years, respectively.  Burt stated that 90% of all lesions in the permanent first molars of school children are pit and fissure lesions.  According to 2004 data, 42% of children and young adults aged 6-19 years had dental caries in their permanent teeth.  Prevalence of dental caries seems to increase with age, ranging from 21% among those aged 6-11 years to 67% in adolescents aged 16-19 years.  About 44% of carious lesions in primary teeth are found on the pits and fissures of molars.  Even though gradually adapted by our profession, pit and fissure sealants are still the best examples of preventive dentistry.  One of the reasons for its gradual adaption is the cost associated with its application.  The matter of great concern these days is the ever-rising costs related to various dental treatments. The cost-benefit analysis of preventive measures should be done if we want them to reach as many people as possible.
| Sneak Peak into the Past|| |
Physically blocking the pits, fissures, and small carious lesions was thought to prevent caries by Hunter in 18 th century.  However, in about 1895 fillings, fissures with zinc phosphate was advocated by Wilson.  Later in 1923, Hyatt proposed the prophylactic odontotomy.  In 1929, Bodecker thought of eradicating the fissures.  However, in 1942, Klein and Knutson used silver nitrate in decreasing the enamel solubility of pits and fissures.  None of these attempts were successful enough to overcome the pit and fissure caries. The first investigation with pit and fissure sealant was conducted using a cyanoacrylate material.  The introduction of the first dental pit and fissure sealant was Nuva-Seal (L.D. Caulk) in February 1971 by Buonocore. Pit and fissure sealants were first accepted by the American Dental Association in 1976. 
| The Better Side of Sealing|| |
There are always two sides of a coin. There are some intangible benefits of sealing the teeth surfaces. These can be as follows: 
- Prevents futuristic treatments such as restorations, and furthermore pulpectomies, extractions, space maintainers, etc.
- Also, secondary problems such as restorations that induce periodontal problems or fractured cusps
- We prevent further treatment to the tooth; the time that the child as well as the parent needs to come away from work is saved
- The tooth is saved for better esthetics as well as pain caused due to caries or restorations is eliminated. Ultimately, there is also no loss in the tooth structure as sealant application is a noninvasive procedure
- Above all, the main advantage that can affect most of the population is the cost-benefit that is achieved by saving the tooth from further treatments which are definitely more costly than sealant application.
| Factors to be Taken into Consideration || |
No matter how beneficial or advantageous a particular procedure is, it needs to be performed in a certain way keeping several factors in mind.  The same is with sealants, though sealants are excellent as a preventive treatment, it can worsen the state of the tooth if not applied properly. Hence, these things should be considered if we want the sealant to fetch us all of its advantages.  These can be as follows:
- Materials and equipment to be used
- The technique of application
- Selection of the patient as well as the teeth
- Use of adjunctive preventive measures
- Recalling of the patient.
The retention property of sealant is very crucial in maintaining its integrity with the tooth structure. Hence, materials that are more retentive should be used. The durability of the material also counts because if the sealant is not durable and requires frequent re-application, then it might further increase the cost instead of reducing it. One other factor that is responsible for a successful application is the isolation maintained during the procedure. It also adds in the retention of the sealant.
The selection of patients is also a necessary step. As in case of a child with special health-care needs, all the permanent molars should be sealed as soon as it is erupted enough that isolation can be maintained. Furthermore, in children having occlusal caries in one of the molars, all their molars should be sealed. To make the most of it, they must be used in addition with other preventive measures such as fluoride application. CONS et al. (1976) showed that the use of sealants increased the effectiveness of water fluoridation by an additional 20%. And, of course, fluoride application should follow sealant applications.
According to Thylstrup and Poulsen (1976), most sealant failures occur within 6 months of their placement, hence recalls should be done accordingly.
- A 10-year report on the effectiveness of a single application of a sealant was published by Simonsen.  In that report, a matched-pair analysis of sealed and unsealed teeth was carried out, and teeth were sealed with a single application of sealant to caries-free surfaces. The study population consisted of 200 patients between the ages of 5 and 15 years who received pit and fissure sealant at Group Health Medical Center in Bloomington, Minnesota. The caries-susceptible posterior teeth were sealed with Concise Brand White Sealant, 3M Dental Products, by a single operator in a fully equipped operatory with a single assistant. All patients from both sealed and control groups were recalled at 1-3, 5, and 10 years. A single sealant application saved 4.7 surfaces per child from restoration over the 10-year period or 0.47 surfaces per child per year. If sealants were reapplied routinely to partially missing areas, as would be expected in a normal dental practice, it can be assumed that essentially all amalgam restorations in the sealed group could be prevented. This would mean that 82 surfaces, or 6.8 surfaces per child, or 0.68 surfaces per child per year would be prevented from restoration. From the above study, the following conclusion can be drawn: It is 1.6 times as costly to restore the carious lesions in the first permanent molars in an unsealed group of 5-10-year-old children having in a fluoridated area than it is to prevent with a single application of pit and fissure sealant, the greater number of lesions will be observed if pit and fissure sealant prevention is not utilized.
| Conclusion|| |
A procedure that has several positive effects cannot be compared with cost. The value of prevention is generally underestimated as compared to restorations. Sealants undoubtedly have a place in the caries preventive armamentarium of general and pediatric dental practice. If used judiciously, they can prove to be really beneficial to prevent caries as well as cost-effectiveness. When sealant application is combined with the effective use of fluorides, the combination can prevent caries entirely in many children.  The cost-effectiveness of sealants in relation to other methods of caries prevention will ultimately determine their impact on a national or international level. Burt  stated that cost-effectiveness of sealants would be enhanced by:
- Applying the most recently developed sealants in which retention rates appear to be most favorable
- Their applications in areas where proximal caries are low
- With meticulous application of sealant, maintenance by resealing of permanent and primary teeth, and application of other preventive measures, 96% of children can be kept caries-free.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Stamm JW. The use of fissure sealants in public health programs: A reactor's comments. J Public Health Dent 1983;43:243-6.
Moses J, Rangeeth BN, Gurunathan D. Prevalence of dental caries, socio-economic status and treatment needs among 5 to 15 year old school going children of Chidambaram. J Clin Diagn Res 2011;5:146-51.
Burt BA. Tentative analysis of the efficiency of fissure sealant in a public program in London. Community Dent Oral Epidemiol 1977;5:73-7.
Marthaler TM. Changes in dental caries 1953-2003. Caries Res 2004;38:173-81.
Simonsen RJ. Cost effectiveness of pit and fissure sealant at 10 years. Quintessence Int 1989;20:75-82.
Harrison L. Rationale and guidelines for pit and fissure sealants. ASDC J Dent Child 1983;50:156.
Simonsen RJ. Retention and effectiveness of dental sealant after 15 years. J Am Dent Assoc 1991;122:34-42.
Feigal RJ, Donly KJ. The use of pit and fissure sealants. Pediatr Dent 2006;28:143-50.
Hyatt TP. Prophylactic odontotomy: The cutting into the tooth for the prevention of disease. Dent Cosmos 1923;65:234-41.
Bodecker CF. Eradication of enamel fissures. Dent Items Interest 1929;51:859.
Klein H, Knutson JW. XIII. Effect of ammoniacal silver nitrate on caries in the first permanent molar. J Am Dent Assoc 1942;29:1420-6.
Cueto EI, Buonocore MG. Adhesive Sealing of Pits and Fissures for Caries Prevention, IADR Abst.# 400. International Association for Dental Research. In 43 rd
General Meeting, Toronto; 1965.
Cueto EI, Buonocore MG. Sealing of pits and fissures with an adhesive resin: Its use in caries prevention. J Am Dent Assoc 1967;75:121-8.
Mitchell L, Murray JJ. Fissure sealants: A critique of their cost-effectiveness. Community Dent Oral Epidemiol 1989;17:19-23.
Graves RC, Bohannan HM, Disney JA, Stamm JW, Bader JD, Abernathy JR. Recent dental caries and treatment patterns in US children. J Public Health Dent 1986;46:23-9.