ADA and AAPD sealant guideline (2016): seal sound and noncavitated occlusal surfaces, and seal them rather than varnish them

What it says#

The ADA Council on Scientific Affairs, the ADA Center for Evidence-Based Dentistry and the American Academy of Pediatric Dentistry convened a panel in 2014 to update the ADA's 2008 sealant recommendations. The panel asked four questions: sealants versus no sealants, sealants versus fluoride varnishes, one sealant material versus another, and adverse events. All four are written for pits and fissures of occlusal surfaces of primary and permanent molars on teeth deemed to have clinically sound occlusal surfaces or noncavitated carious lesions. The panel used GRADE to rate the certainty in the evidence and to move from the evidence to the decisions, and it produced three main recommendations.

On the first question, data from nine randomized controlled trials showed that in children and adolescents with sound occlusal surfaces, sealants compared with nonuse reduce the incidence of occlusal carious lesions in permanent molars by 76% after 2 to 3 years of follow-up (odds ratio, 0.24; 95% confidence interval, 0.19-0.30). In absolute terms, for a population with a caries baseline prevalence of 30%, 207 carious lesions would be prevented out of 1,000 sealant applications (95% CI, 186-225 fewer lesions). In a mixed population of sound surfaces and noncavitated lesions the reduction was 75% (OR, 0.25; 95% CI, 0.19-0.34). The panel rated the overall quality of that evidence moderate, downgraded for serious risk of bias, and issued a strong recommendation for the use of sealants compared with nonuse in primary and permanent molars with both sound occlusal surfaces and noncavitated occlusal carious lesions in children and adolescents.

On the second question, three trials suggested that sealants compared with fluoride varnishes may reduce the incidence of occlusal carious lesions in permanent molars by 73% after 2 to 3 years (OR, 0.27; 95% CI, 0.11-0.69), or 196 lesions prevented per 1,000 applications at a 30% baseline (95% CI, 72-255 fewer). In the mixed sound-plus-noncavitated population, sealants reduced caries by 34%, but that difference was not statistically significant (OR, 0.66; P = .30; 95% CI, 0.30-1.44). The quality was low, downgraded for risk of bias and inconsistency, so the recommendation to prefer sealants over fluoride varnish is conditional.

On materials, the head-to-head comparisons did not separate the products. Glass ionomer sealants compared with resin-based sealants showed a 37% reduction in lesions that was not statistically significant (OR, 0.71; 95% CI, 0.32-1.57) but roughly five times the risk of losing retention (OR, 5.06; 95% CI, 1.81-14.13). Glass ionomer compared with resin-modified glass ionomer showed no significant caries difference (OR, 1.41; 95% CI, 0.65-3.07) and about three times the retention loss. The panel was unable to determine superiority of one type of sealant over another owing to the very low quality of evidence, and recommends that any of the materials evaluated can be used, in no particular order, as a conditional recommendation on very low-quality evidence. Its practical steer is about isolation: where dry isolation is difficult, such as a partially erupted tooth with soft tissue impinging, a more hydrophilic material such as glass ionomer is preferable; where the tooth can be isolated and long-term retention is wanted, a resin-based sealant may be preferable.

On safety, the concern the panel addressed is bisphenol A. It reports that the evidence does not support the transient effect of a small amount of BPA in placing patients at risk, that studies of teeth with fully or partially lost sealants found no greater risk of carious lesions than teeth that had never been sealed, and that two randomized trials measuring adverse effects found no events. The companion systematic review, which screened 2,869 records and included 24 articles representing 23 studies, carries the long-term numbers: at 7 or more years of follow-up, sealants versus no sealants gave an OR of 0.15 (95% CI, 0.08-0.27) on moderate-quality evidence, and sealants versus fluoride varnish an OR of 0.19 (95% CI, 0.07-0.51) on low-quality evidence.

Who it applies to#

Children and adolescents, primary and permanent molars, occlusal surfaces. The panel names its audience broadly: general and pediatric dentists and their support teams, dental hygienists, dental therapists, public health dentists, community dental health coordinators, pediatricians and primary care physicians, and policy makers.

Adults are outside the evidence. No data on the effect of sealants in adult patients were identified for any question. The panel allows that similar treatment effects may be expected in other age groups, particularly adults with a recent history of dental caries, but says the lack of direct evidence restrained it from a more definitive recommendation. Cavitated lesions are also outside it; those are the subject of the 2018 nonrestorative guideline and the 2023 restorative guideline, which use the lesion stages of the ADA Caries Classification System.

What changed#

This is an update of the ADA's 2008 recommendations on sealants for occlusal surfaces of primary and permanent molars. The visible difference is method: the 2016 panel built the recommendations on a de novo systematic review of randomized controlled trials and graded them with GRADE, so each recommendation now carries an explicit quality rating and an explicit strength. That is what produces the split readers notice, a strong recommendation for sealing rather than not sealing and only a conditional one for sealing rather than varnishing. This entry did not compare the 2008 and 2016 texts line by line.

The other change is tone. The panel closes by recommending that clinicians reorient their efforts toward increasing the use of sealants on occlusal surfaces of primary and permanent molars in children and adolescents, and notes that sealants are still underused despite documented efficacy and available guidelines.

Where the source is#

The link under the title is the ADA's sealant guideline page, which opens the chairside guide and points to the JADA article. The full guideline text was read for this entry from the AAPD's copy of the published article (JADA 2016;147(8):672-682), which carries the recommendation table, all four question sections and the remarks; jada.ada.org itself blocks automated access. The companion systematic review (JADA 2016;147(8):631-645) is behind JADA access, so its long-term odds ratios here come from the published PubMed abstract. The identical guideline was published concurrently in Pediatric Dentistry in September and October 2016, and either citation may be used. The chairside guide is free and may be copied and distributed for noncommercial purposes without prior ADA approval.