O. Doli, et al., Application of composites, compomers and glass-ionomer cements ...

Contemporary Materials I2 (2010)

Original scientific papers

Page 168 of 174

UDK 616.314002
DOI: 10.5767/anurs.cmat.100102.en.168D

APPLICATION OF COMPOSITES, COMPOMERS AND

GLASS-IONOMER CEMENTS IN CARIES PREVENTION
ON OCCLUSAL TOOTH SURFACE
O. Doli, J.Vojinovi,* M. Obradovi, S. Sukara, . Koji, N. Trti
University of Banja Luka, Faculty of Medicine, Save Mrkalja 14,
Banja Luka, Republic of Srpska, B&H
Abstract: Caries is more likely to occur in fissures and pits on occlusal tooth surface than on its smooth surface. Prevention of dental caries on occlusal surface is possible by
applying composites, compomers and glass-ionomer cements, as methods of fissure and pit
sealing, immediately after tooth eruption. The development of adhesive dentistry has enabled effective implementation of this method, which has become one of the first minimally
invasive procedures. Although it is very simple and economically viable, the method of fissure and pits sealing is still rarely applied in our area. The paper outlines characteristics of
materials used in the method of fissure and pits sealing and shows the state of sealing, retention of sealant on the first permanent molars in a three-year period, after the first, second
and third year of fissure and pits sealing .
Keywords: caries, composites, compomers, glass-ionomer cements, fissure and pits
sealing.

1. INTRODUCTION

Dental caries is a destructive disease of hard

dental tissues. Caries and periodontal disease are the
most widespread pathological processes of modern
civilization, in general. Also, dental caries is the
most frequent chronic disease in children [1].
Current knowledge about the local origin of
disease, its pathogenesis and numerous exogenous
and endogenous factors that slow down, accelerate
or prevent its development, indicate a complex interaction between cariogenic microorganisms organized in dental plaque, the presence of carbohydrates,
defense capacity of saliva and resistance of enamel
mineral structure.
Early caries occurrence is tightly connected
with occlusal morphology and is more frequent in
pit and fissures than on smooth dental surface. The
morphology of the occlusal surface is very complex,
and the dimensions of the fissures varied not only
between different types of teeth, but also in the same
part of the occlusal surface of teeth. Fissures can
reach deep into the occlusal surface of teeth and may
show narrowing or they can vary in depth in different places. The depth of fissures ranges from 401220 m, obliquity of fissures walls is the extent of
35 to 100 , and width can be 6-180 m. In many studies, fissures were classified only on the basis of
*

Corresponding author: [email protected]

their morphological characteristics, as different U,

V, Y1 and Y2 types of fissures. Fissures are sometimes classified in relation to the depth of the gap in
fissures bottom as shallow, deep and intermediate
type [2,3].
Since endogenous and exogenous application
of fluoride cannot reduce occlusal caries completely,
many studies attempted to arrive at other prophylactic measures. In 1985, Wilson put cement in the pits
and fissures. After him, many researchers applied
various materials in pit and fissures (silver nitrate,
zinc chloride, copper amalgam, oxyphosphate
cement, etc.) in order to prevent caries [4].
Finding specific prophylactic measures for
prevention of occlusal dental caries is particularly
topical since the year 1967 when Cueto and Buonocore introduced the process of pit and fissures sealing. Pit and fissure sealing is a specific clinical procedures that applies appropriate application of materials in order to protect the pit and fissures on occlusal surfaces from the impact of cariogenic oral environment factors. It is one of the most effective methods in preventing tooth decay. Ripple 1976, Gwinett 1976, and Simonsen 1978, Houpt et al. in 1986
and numerous other authors have improved that procedure thus contributing to a number of clinical and
in vitro studies. [5,6,7,8] At the American Dental
Association (ADA) meeting in 1983, it was conclu-

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Contemporary Materials I2 (2010)

ded that the application of sealant is safe and effective prophylactic measure that should be an integral
part of prevention program [4].
The pharmacodynamic effects of modern sealant imply the following:
There is no systemic toxicity;
They are safe;
They do not damage the hard and soft tissues;
They do not disturb the occlusion;
They prevent the effect of dental plaque on the tooth surface (pits and fissures);
They prevent the development of cariogenic flora
which is already present in pits and fissures;
They prevent further progression of initial enamel
demineralization.
2. MATERIALS FOR PIT AND
FISSURE SEALANTS
Today, the sealants are available as composite, compomer and glass-ionomer materials.

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the radiation consequences. The filler improvement

decreased the porosity of materials and enhanced
physical and mechanical properties. Photosensitive
composite resins are mainly made of mono-and bifunctional photosensitive monomers and initiators,
which are responsible for the beginning of chains,
composed of free radicals providers [10,11,12].
The clinical procedure of composite sealant
retention is achieved by etching the enamel surface
with acid. Acid etching is the physical-chemical process that increases the active surface of the enamel,
for adhesion of composite materials. This excludes
the microgaps occurrence between enamel and materials. The phosphoric acid action on enamel structure
leads to the dissolution of hydroxyapatite. Along
with that different acid precipitation of calcium
phosphate occurs. It is considered that the time of
etching enamel with 37% phosphoric acid in permanent teeth should not be longer than 30 seconds,
while in primary teeth should equal between 30 and
60 seconds [12,13,14].
2.2. Composite sealants with fluoride

2.1. Composite sealants

Composite sealants prevent oclussal caries

primarily through physical obturation of pit and fissures. They do not contain active cariostatic components and their preventive role is based solely on
physical isolation of fissures from oral environment
to prevent the flow of nutrient substances by bacteria
that are found in the deeper parts of the fissure
system [10,11].
In modern dentistry the first fissure sealant
was the materials on the basis of BIS-GMA. They
are the same structure as composite materials for restoration, but contain much less filler, to reduce their
viscosity and to allow them better penetration into
pit and fissures. In composite sealant color pigments
can also be added for better visibility and control, as
well as cariostatic substance such as fluoride.
[10,12].
Initiation of polymerization of the composite
sealants can be chemical or photochemical. Today,
chemically initiated sealants are rarely used. Serious
complaints have been addressed to ultraviolet light
initiated sealants. These complaints were in terms of
harmful radiation to oral tissues and the low depth of
light penetration through the material. These materials were succeeded by the materials where the
polymerization process starts with visible light of
wavelength 470 nm. The advantages of visible light
are reflected in lower light intensity, greater depth of
penetration and penetration through the enamel, as
well as less exposure to radiation, and less danger of

In the beginning of the nineties there develops

composite sealants which have the ability of releasing fluoride, as a result of the tendency to add a
well-known caries protective effect of fluoride such
good mechanical role of composite sealants, like
physical isolation of fissures from oral environment.
Composite materials have excellent mechanical properties, and fluoride should have a therapeutic and
preventive effect due to the mechanism of enamel
remineralization.
Composite sealants with fluorides (2-5% NaF)
have led to increased concentrations of fluoride in
enamel and reduce enamel solubility in acids. Composite sealants with fluoride have effective mechanical barriers, enhance enamel resistance and provide
remineralization process. Studies have shown that
the effect of fluoride from composite materials is
much weaker than the fluoride from glass ionomer
sealants [10,15,16].
2.3. Compomer sealants

Compomers are modified composite resins

with polyacides and belong to the group of hybrid
dental materials. Aesthetic properties of traditional
composite systems in compomers combined with the
properties of fluoride and adhesion of glass-ionomer
cements. The level of fluoride release in compomer
and composite sealants with fluoride is lower than in
glass-ionomer materials [10,17]. Retention rate of
compomer sealants is similar to the composite sea-

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Contemporary Materials I2 (2010)

lants. Clinical trials have shown that compomer sealants fully compete with composite sealants except
for the marginal adaptation [10,18].
2.4. Glass-ionomer sealants

Glass-ionomers are used as fissure sealants

due to their chemical bond to enamel without previous etching and continuous fluoride ion release and
incorporation into the surrounding mineralized enamel and dentin [5,19].
The basic advantages of glass-ionomers such
as the possibility of chemical bonding to enamel, the
continuous release of fluoride ions from a base matrix and the incorporation of fluoride ions into the
surrounding mineralized enamel and dentin were
used for the production of glass-ionomer sealants.
The first systematic report about glass-ionomer cements as pit and fissure sealants in 1996 stated that
glass-ionomer cements did not show worse cariesprotective effect than composite sealants although
they had lower retention [20].
It is necessary to provide a dry working field
when using composite sealants. Glass-ionomer sealants can be an alternative to composite materials,
especially when it is difficult to set composite sealant, or in wet conditions. Thanks to the hydrophilic
properties, glass-ionomer cements are not as sensitive to moisture as composite materials [21]. The release of fluoride from glass-ionomer sealants provides
their strong diffusing into enamel so prolonged fluoride release continues after the sealants drop out
[22,23].
Some authors even recommend setting up
glass-ionomers as temporary sealants to provide an
adequate barrier to the penetration of microorganisms and also act as a fluoride reservoir while the
conditions are met for setting up "permanent" composite sealant [24].
3. OBJECTIVE
The aim of this study was to examine the durability and retention of sealant on the first permanent molars in the period of three years, separately
after the first, second and third year of placing sealant on teeth.
4. MATERIAL
Data was collected from medical records of
patients who had their first permanent molars sealed
between January 01, 2007 and March 01, 2010. Pati-

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ents, both male and female, ranged in age from 2 to

12 years.The criteria for teeth selection were intact
first permanent molars that did not show any sign of
caries development after a standard examination
using dental probe and dental mirror by standard
dental illumination. The first permanent molars that
have not erupted completely were excluded.
During the period of the research, the three
dentists placed a total of 236 sealants in first permanent molars, all meeting the research inclusion criteria (Table 1).
Table 1. Sealed teeth by the year of sealing
year
year
year
teeth
2007
2008
2009
16
24
18
15
26
18
21
14
36
26
22
10
46
27
27
14
total
95
88
53

total
57
53
58
68
236

Optimal field isolation using the rubber dam

is often not possible in children, so cotton roll isolation and suction were used for sealants to ensure a
moisture free occlusal surface. Ultra-Etch (35%
phosphoric acid gel) was applied to air-dried tooth
surfaces for 30 seconds. After etching, the acid was
rinsed with water for 30 seconds and the teeth air
dried for 15 seconds. In all cases Fisurit-F (VocoGermany) pit and fissure sealant was applied and
light cured for 30 seconds. After that retention and
occlusion were checked and polishing and local applications of high concentrations fluorides were done.
Sealant integrity after the first, the second and
the third year was recorded as: A - intact, the tooth
remains under observation; B - sealant partly or
completely absentwith no caries; the tooth needs to
be resealed; C - caries detected under or around the
sealant; the tooth needs to be restored- the first class
of filling; D - caries detected under or around the sealant; the tooth needs to be restored- the second class
of filling.
5. RESULTS
The results of sealant condition in the first
permanent molars over the three years period are
shown in Table 2 and Figure 1.
A total number of 236 sealants were analyzed.
Over the 3-year period, 204(86.44%) sealed first
permanent molars were intact, 10 (4.24%) were resealed, 14 (5.93%) were restored with one surface the
first class of filling and 8 (3.39%) were restored with
the second class of filling. In other words, 90.68% of

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Contemporary Materials I2 (2010)

teeth were caries free (intact and resealed). After

three years there was no statistically significant difference of treatments of failed sealants between groups of teeth. Also, there was no statistically significant difference after the first and the second year.

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The annual distribution of repeated treatments

in first permanent molars is presented in Figure 2
and in Table 3.

Table 2. Sealant condition after three years.

A-intact

B-resealed

teeth
16
26
36
46

n
45
47
51
61

%
78,95
88,68
87,93
89,71

n
3
2
2
3

%
5,26
3,77
3,45
4,41

total

204

86,44

10

4,24

C-restored (the
first class of
feeling)
n
%
6
10,53
2
3,77
3
5,17
3
4,41
14

5,93

D-restored (the
first class of
feeling)
n
%
3
5,26
2
3,77
2
3,45
1
1,47
8

3,39

Caries Free (intact and

resealed)A+B
n
48
49
53
64

%
84,21
92,45
91,38
94,12

214

90,68

Figure 1. Sealant condition after three years

There was a 4.24% sealant failure rate in the

first year, in total. 3.51% of upper right first permanent molars (16) were resealed, 3.51% of teeth were
restored with the first class of filling, and 1.75% were restored with the second class of filling. 1.89% of
upper left first permanent molars (26) were resealed,
there were no restored teeth. 1.72% of lower left first
permanent molars (36) were resealed, 1.72% were
restored with the first class of filling and 1.72% was
restored with the second class of filling. 1.47% of lower right first permanent molars (46) were resealed,
there were no restored teeth.
There was a 5.09% sealant failure rate in the
second year of study. There were no resealed upper
right first permanent molars (16). Also, there were
no restored upper right first permanent molars (16)
with the second class of filling and 5.26% were restored with the first class of filling. 1.89% of upper
left first permanent molars (26) were resealed,
1.89% were restored with the first class of filling,

and 3.77% were restored with the second class of filling. There were no resealed lower left first permanent molars (36), 1.72% were restored with the first
class of filling and there were no restored teeth with
the second class of filling . 1.47% of lower right first
permanent molars (46) were resealed, 2.94% were
restored with the first class of filling, and 1.47% were restored with the second class of filling.
There was a 4.23% sealant failure rate in the
third year of study. 1.75% of upper right first permanent molars (16) were resealed, 1.75% were restored
with the first class of filling and 3.51% were restored with the second class of filling. There were no
resealed upper left first permanent molars (26),
1.89% were restored with the first class of filling
and there were no restored teeth with the second
class of filling. 1.72% of lower left first permanent
molars (36) were resealed, 1.72% were restored with
the first class of filling and 1.72% were restored
with the second class of filling. 1.47% of lower right

O. Doli, et al., Application of composites, compomers and glass-ionomer cements ...

Contemporary Materials I2 (2010)

first permanent molars (46) were resealed, 1.47%

were restored with the first class of filling there were

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no restored teeth with the second class of filling.

Table 3. The annual distribution of repeated treatments in first permanent molars

the first year

the second year

Bresealed

Crestored
(the first
class of
feeling)

Drestored
(the
second
class of
feeling)

16

3,51

3,51

26

1,89

36

1,72

46

total

the third year

Bresealed

Crestored
(the first
class of
feeling)

Drestored
(the
second
class of
feeling)

Bresealed

Crestored
(the first
class of
feeling)

Drestored
(the
second
class of
feeling)

1,75

0,00

5,26

0,00

1,75

1,75

3,51

0,00

0,00

1,89

1,89

3,77

0,00

1,89

0,00

1,72

1,72

0,00

1,72

0,00

1,72

1,72

1,72

1,47

0,00

0,00

1,47

2,94

1,47

1,47

1,47

0,00

2,12

1,27

0,85

0,85

2,97

1,27

1,27

1,69

1,27

Figure 2. The annual distribution of repeated treatments in first permanent molars

6. DISCUSSION
Preventive method of sealing pit and fissures
is an important procedure because the specific fissure morphology gives condition that caries in pit and
fissures can not be avoided, in spite of balanced diet,
daily hygiene, fluoridation and regular dental checkups.
When applying sealants it is necessary to have
a close contact between fissures and sealants. This
requires checking-up of sealants and possibly resealing so as to avoid the caries development.
Our study showed that the upper right first
permanent molars (16) often require resealing. Also
the upper right first permanent molar teeth were the
teeth most likely to require restoration. This was
consistent with other research findings where it is in-

dicated that the upper molars are notorious for sealant loss [25,26]. A possible explanation is that it is
difficult to set up the sealant and cure it on time, due
to the posterior position in the mouth, an imperfect
lighting system for curing. Furthermore, the dentists
in this study were right-handed and thus lingual grooves of teeth at the right side were not as easily seen.
Most of the children were right-handed and we could assume that they brushed their teeth better on the
left side of their mouths.
The highest sealant failure rate was after the
second year of sealing. According to Whitehurst and
Sony, the biggest loss of sealant occurred during the
first 6 months, and only 18% of first and second permanent molars were completely sealed after the first
year [27]. Also, Stephen et al. field study indicates

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Contemporary Materials I2 (2010)

that only 12 of nearly 400 teeth remained completely

sealed after the first year [25].
A high sealant retention rate of 76-85% after
10 months was observed by Shashikiran et al, which
could be attributed to their use of rubber dam isolation and sealant reapplication [26].
Considering possible reasons for failure of resin sealant, Anson et al. listed poor placement technique (inadequate moisture control, not sealing all
pits/fissures, inadequate etching, inadequate rinsing
and drying, and insufficient curing time); material
wear; and finally, failure due to a combination of
these factors [27]. Other factors, according to some
authors, which influence sealant retention, include
the position of the tooth in the mouth, the skill of the
dentist, and the age of the patient [25].
7. CONCLUSION
Our research, as well as numerous other studies, has shown that pit and fissure sealants were retained for a longer period. There was only a small sealant failure rate and developed carious lesions on occlusal surfaces after sealant failure, thus illustrating
the necessity of sealing the teeth, as well as important caries preventive measures.
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