Pit-and-fissure sealants
- ADA/AAPD (2016) guideline: seal pits and fissures of primary and permanent molars in children and adolescents; sealants also slow or stop noncavitated pit-and-fissure lesions.
- Resin-based sealants retain best; glass ionomer sealants are useful when moisture control is poor (partially erupted molars) as an interim measure.
- Steps: clean, isolate, etch, rinse, dry to a frosty surface, apply, cure, check retention and occlusion.
- Moisture or saliva contamination after etching is the most common cause of sealant loss; re-etch briefly if contaminated.
CAMBRA: balance of disease indicators, risk factors and protective factors
| Category | Examples |
|---|---|
| Disease indicators | Visible cavities into dentin, radiographic lesions into dentin, white spot lesions, restorations placed in the last 3 years |
| Biological risk factors | Heavy plaque, frequent snacking (more than 3 times a day between meals), deep pits and fissures, low saliva flow or saliva-reducing medications, exposed roots, orthodontic appliances, recreational drug use |
| Protective factors | Fluoridated water and toothpaste, prescription fluoride, adequate saliva, xylitol, calcium phosphate products, antibacterial rinses |
- Risk levels: low, moderate, high, and extreme (high risk plus severe hyposalivation).
- Any disease indicator usually places a patient in at least high risk; risk is reassessed at each recall.
Silver diamine fluoride (SDF)
- 38% SDF is FDA-cleared as a desensitizer; using it to arrest caries is off-label but supported by evidence and by AAPD guidance.
- Silver is antibacterial; fluoride (commonly cited at about 44,800 ppm) supports remineralization. Applied without removing caries; twice-yearly application arrests more lesions than once a year.
- Arrested lesions stain black, so informed consent is essential; it also stains skin and clothing temporarily.
- Contraindications: silver allergy; avoid on ulcerated or painful mucosa (ulcerative gingivitis or stomatitis); not a treatment for teeth with signs of irreversible pulpitis or abscess.
⚠️ Common traps
- Avoiding sealants over early noncavitated lesions: sealing them is recommended and slows progression.
- Promising patients that SDF-treated lesions will look normal: arrested lesions turn black.
- Treating CAMBRA as a one-time label: risk is reassessed.
- Blaming sealant loss on the material first: contamination during placement is the usual cause.
Mini-quiz
- What is the most common reason a resin sealant fails?
- A partially erupted second molar cannot be kept dry. Which approach is most reasonable?
- Which finding is a CAMBRA disease indicator rather than a risk factor?
- Parents should be told that after SDF, an arrested carious lesion will usually:
- Which is a contraindication to SDF?
Answer key: 1 C · 2 B · 3 A · 4 C · 5 B