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Pit and fissure sealant
L e t t e r s to t h e E d it o r
determined that the cards would not be printed in time for insertion by the printer in the January issue. It is planned to in clude these tear-out sheets in a future edi tion of /ADA. This may, in fact, be a better way to use these inserts, as this would allow a second exposure of the profession to the new guidelines. In addition to providing these inserts to dentists, the council is also planning to develop an information sheet to be given to patients by the dentist. Similar in con cep t to the Dental Drug Inform ation Sheets for patients, which can currently be ordered from the ADA, this sheet will discuss the cardiovascular conditions for which bacterial endocarditis prophylaxis is indicated, the fact that it should be ini tiated in susceptible patients whenever a dental procedure is likely to cause bleed ing, and the various regimens. CLIFFORD W. WHALL, JR., PhD A SSISTA N T SECRETARY COUNCIL ON DENTAL THERAPEUTICS
Pit and fissure sealant □ Dr. Brian Burt is to be complimented on his excellent report on pit and fissure sealant on behalf of the Council on Dental Research (January). I would like to make one or two comments in an attempt to forestall possible m isinterpretation of some of Dr. Burt’s statements. I believe we should give credit to the concept of pit and fissure sealing to a paper earlier than the prophylactic odon totomy paper of Hyatt (1923). In 1895, Dr. I. P. W ilson of Burlington, Iowa, pub lished a sagacious paper in Dental Digest in which he describes the benefits of seal ing pits and fissures of newly erupted mo lars with “cement” for caries protection. I wonder if this paper is not the first ref erence in the dental literature on the sub ject of pit and fissure sealing? I also believe Dr. Burt was a little hesi tant to be as decisive in some of his com ments as perhaps the literature would allow him to be. For example, he states that . .carious lesions rarely progress w hen the sealan t has been properly applied. . . .” Later in the paper he states that . . where the sealant is properly applied and fully retained, caries rarely occurs.” Although we are justifiably cau tious in making concrete statements of ef fect, I believe that there is ample support in the literatu re to make the general 302 ■ JADA, Vol. 110, M arch 1985
statements that carious lesions never pro gress when the sealant has been properly applied and that caries never occurs under a properly applied and fully re tained sealant. Leaving open the possibil ity that caries can start or progress under properly applied sealant may discourage some clinicians from using pit and fissure sealant. Surely, it is in cases of improp erly applied sealant that we should be concerned. Similarly, the statement “ . . .half the sealants are detectable after 5 years al though they are worn down” may lead to some misinterpretation by practitioners. Perhaps the words “show wear,” rather than “worn down,” may be a better de scription of the actual clinical picture of 5-year-old sealant in a normal situation. Finally, I believe that we should re evaluate the assumptions that sealing a tooth that has remained cariesfree for 4 years after eruption or that sealing a tooth with interproximal caries are necessarily ill advised. As a result of long-standing beneficial effects of water fluoridation and topical fluoride treatments of one form or another, it is not now so in frequent to see pit and fissure caries de layed into the third and fourth decade of life in previously cariesfree individuals. Additionally, radiographic diagnosis of interproximal caries need not necessarily le a d to re s to ra tio n of th a t su rfa c e . R em in eralizatio n is a treatm ent that should be attempted for many incipient enamel lesions. If this should fail, there are restorative procedures and materials available that do not necessarily mean removal of the occlusal surface for the res toration of interproximal caries. In both of these examples, sealant would be a useful adjunct treatment even though caries has been diagnosed on the proximal surface and/or the patients may be considerably older than usual for sealant application. RICHARD J. SIMONSEN, DDS, MS DEPARTMENT OF RESTORATIVE DENTISTRY UNIVERSITY OF CONNECTICUT SCHOOL OF DENTAL MEDICINE FARMINGTON, CT
garding the transfer of drugs to infants during breast-feeding (February 1983). I have used this article many times in my own practice to help pregnant women understand some of the consequences of taking various drugs, but the article did not mention local anesthetics and their possible side effects. I would like the au thors to comment on the subject so that the general readership of JADA will have an update in this area. CHARLES G. JOHNSON, DMD HOT SPRINGS, AR
□ Comment: Regarding Dr. Johnson’s request concerning information pertain ing to the transfer of local anesthetics by way of breast milk, I am afraid that I have not found any literature on the topic. It is possible to theorize, however, that agents w ith a low pKa su ch as lid o c a in e , m epivacaine, and prilocaine, and which exist as a base at physiologic pH would disseminate across the milk-blood barrier to more of an extent than agents with a h ig h e r p K a s u c h as p r o c a in e , b u pivacain e, and tetracaine. A nother consideration is the degree of protein binding in the maternal plasma, which ranges from 65% for lidocaine to 90% for bupivacaine and tetracaine. A final con sideration regarding the availability of drug to the m ilk pool is the degree of ioni zation of the anesthetic. The typical anes thetic solution is at a pH of 6.0 with nearly all of the drug in the ionized form, making it difficult to cross the milk-blood barrier. At p h y s io lo g ic pH of 7 .4 , 2 0 % of lidocaine exists as a free base, making it likely to cross into the milk. As can be seen from the foregoing an swer, the metabolism of local anesthetics is complex, and to answer Dr. Johnson completely would require more material than is possible in a letter. DONALD I. GEORGE, JR., DMD, MS LOUISVILLE, KY
□ The report on cost-effectiveness of sealants (January), should be read by all dentists and third-party carriers. Dr. Burt not only explains the very latest on seal ant use and possible effectiveness, but also describes the views of a third-party dental carrier and why a procedure may be accepted or rejected. As dentists, to be effective in communicating with thirdparty carriers, we must be able to under stand their position. RALPH E. HORTON, DDS MOLINE, IL
L ocal anesthetics and pregnancy □ I compliment Drs. Donald I. George and Thomas J. O’Toole on their article re
“Milk-blood barrier” of m amm ary gland alveolus. Arrow A shows passive diffusion of m aterial from lumen of blood vessel into lumen of alveolus. Small un-ionized molecules must cross: (a) endothelial cell of blood vessel; (b) basement membrane of blood ves sel; (c) interstitial breast space; (d) myoepithelial cell of alveolus; (e) basement membrane of alveolus; and (f) interalveolar spaces.
determined that the cards would not be printed in time for insertion by the printer in the January issue. It is planned to in clude these tear-out sheets in a future edi tion of /ADA. This may, in fact, be a better way to use these inserts, as this would allow a second exposure of the profession to the new guidelines. In addition to providing these inserts to dentists, the council is also planning to develop an information sheet to be given to patients by the dentist. Similar in con cep t to the Dental Drug Inform ation Sheets for patients, which can currently be ordered from the ADA, this sheet will discuss the cardiovascular conditions for which bacterial endocarditis prophylaxis is indicated, the fact that it should be ini tiated in susceptible patients whenever a dental procedure is likely to cause bleed ing, and the various regimens. CLIFFORD W. WHALL, JR., PhD A SSISTA N T SECRETARY COUNCIL ON DENTAL THERAPEUTICS
Pit and fissure sealant □ Dr. Brian Burt is to be complimented on his excellent report on pit and fissure sealant on behalf of the Council on Dental Research (January). I would like to make one or two comments in an attempt to forestall possible m isinterpretation of some of Dr. Burt’s statements. I believe we should give credit to the concept of pit and fissure sealing to a paper earlier than the prophylactic odon totomy paper of Hyatt (1923). In 1895, Dr. I. P. W ilson of Burlington, Iowa, pub lished a sagacious paper in Dental Digest in which he describes the benefits of seal ing pits and fissures of newly erupted mo lars with “cement” for caries protection. I wonder if this paper is not the first ref erence in the dental literature on the sub ject of pit and fissure sealing? I also believe Dr. Burt was a little hesi tant to be as decisive in some of his com ments as perhaps the literature would allow him to be. For example, he states that . .carious lesions rarely progress w hen the sealan t has been properly applied. . . .” Later in the paper he states that . . where the sealant is properly applied and fully retained, caries rarely occurs.” Although we are justifiably cau tious in making concrete statements of ef fect, I believe that there is ample support in the literatu re to make the general 302 ■ JADA, Vol. 110, M arch 1985
statements that carious lesions never pro gress when the sealant has been properly applied and that caries never occurs under a properly applied and fully re tained sealant. Leaving open the possibil ity that caries can start or progress under properly applied sealant may discourage some clinicians from using pit and fissure sealant. Surely, it is in cases of improp erly applied sealant that we should be concerned. Similarly, the statement “ . . .half the sealants are detectable after 5 years al though they are worn down” may lead to some misinterpretation by practitioners. Perhaps the words “show wear,” rather than “worn down,” may be a better de scription of the actual clinical picture of 5-year-old sealant in a normal situation. Finally, I believe that we should re evaluate the assumptions that sealing a tooth that has remained cariesfree for 4 years after eruption or that sealing a tooth with interproximal caries are necessarily ill advised. As a result of long-standing beneficial effects of water fluoridation and topical fluoride treatments of one form or another, it is not now so in frequent to see pit and fissure caries de layed into the third and fourth decade of life in previously cariesfree individuals. Additionally, radiographic diagnosis of interproximal caries need not necessarily le a d to re s to ra tio n of th a t su rfa c e . R em in eralizatio n is a treatm ent that should be attempted for many incipient enamel lesions. If this should fail, there are restorative procedures and materials available that do not necessarily mean removal of the occlusal surface for the res toration of interproximal caries. In both of these examples, sealant would be a useful adjunct treatment even though caries has been diagnosed on the proximal surface and/or the patients may be considerably older than usual for sealant application. RICHARD J. SIMONSEN, DDS, MS DEPARTMENT OF RESTORATIVE DENTISTRY UNIVERSITY OF CONNECTICUT SCHOOL OF DENTAL MEDICINE FARMINGTON, CT
garding the transfer of drugs to infants during breast-feeding (February 1983). I have used this article many times in my own practice to help pregnant women understand some of the consequences of taking various drugs, but the article did not mention local anesthetics and their possible side effects. I would like the au thors to comment on the subject so that the general readership of JADA will have an update in this area. CHARLES G. JOHNSON, DMD HOT SPRINGS, AR
□ Comment: Regarding Dr. Johnson’s request concerning information pertain ing to the transfer of local anesthetics by way of breast milk, I am afraid that I have not found any literature on the topic. It is possible to theorize, however, that agents w ith a low pKa su ch as lid o c a in e , m epivacaine, and prilocaine, and which exist as a base at physiologic pH would disseminate across the milk-blood barrier to more of an extent than agents with a h ig h e r p K a s u c h as p r o c a in e , b u pivacain e, and tetracaine. A nother consideration is the degree of protein binding in the maternal plasma, which ranges from 65% for lidocaine to 90% for bupivacaine and tetracaine. A final con sideration regarding the availability of drug to the m ilk pool is the degree of ioni zation of the anesthetic. The typical anes thetic solution is at a pH of 6.0 with nearly all of the drug in the ionized form, making it difficult to cross the milk-blood barrier. At p h y s io lo g ic pH of 7 .4 , 2 0 % of lidocaine exists as a free base, making it likely to cross into the milk. As can be seen from the foregoing an swer, the metabolism of local anesthetics is complex, and to answer Dr. Johnson completely would require more material than is possible in a letter. DONALD I. GEORGE, JR., DMD, MS LOUISVILLE, KY
□ The report on cost-effectiveness of sealants (January), should be read by all dentists and third-party carriers. Dr. Burt not only explains the very latest on seal ant use and possible effectiveness, but also describes the views of a third-party dental carrier and why a procedure may be accepted or rejected. As dentists, to be effective in communicating with thirdparty carriers, we must be able to under stand their position. RALPH E. HORTON, DDS MOLINE, IL
L ocal anesthetics and pregnancy □ I compliment Drs. Donald I. George and Thomas J. O’Toole on their article re
“Milk-blood barrier” of m amm ary gland alveolus. Arrow A shows passive diffusion of m aterial from lumen of blood vessel into lumen of alveolus. Small un-ionized molecules must cross: (a) endothelial cell of blood vessel; (b) basement membrane of blood ves sel; (c) interstitial breast space; (d) myoepithelial cell of alveolus; (e) basement membrane of alveolus; and (f) interalveolar spaces.