Original Article

Effect of Adhesive Application on Sealant Success: A Clinical

Study of Fifth and Seventh Generation Adhesive Systems


Vaibhav Tandon1, Ravishanakar Telgi Lingesha2 , Pradeep Shankar Tangade2, Amit Tirth3, Sumit Kumar Pal3,
Chaitra Telgi Lingesha4, Vikram Arora5, Vipul Yadav6

1
Senior Lecturer, Department of Public Health Dentistry, Kothiwal Dental College & Research Centre, Moradabad, India
2
Professor, Department of Public Health Dentistry, Kothiwal Dental College & Research Centre, Moradabad, India
3
Reader, Department of Public Health Dentistry, Kothiwal Dental College & Research Centre, Moradabad, India
4
Reader, Department of Pedodontics & Preventive Dentistry, Kothiwal Dental College & Research Centre, Moradabad, India
5
Senior Lecturer, Department of Public Health Dentistry Swami Devi Dayal Dental College, Panchkula, India
6
Senior Resident, Department of Public Health Dentistry, Maulana Azad Institute of Dental Sciences, New Delhi, India

Abstract
Objectives: The aim of the study was to compare the effect of fifth and seventh
generation bonding agent on sealant success.
Materials and Methods: Sixty-four school children aged six to nine years received
sealants in four permanent molars in a split mouth design, such that each patient received
sealant in the first permanent molar with fifth generation bonding agent in one arch and
seventh generation bonding agent in the other arch; contra-lateral molars were sealed with
sealant alone. The evaluation was carried out at baseline, three months, six months and 12
months, according to the criteria by Feigal et al, in 2000. Chi- square test was used to
analyze data at P<0.05 level of significance.
Results: Statistically significant differences were found for sealant retention between fifth
generation and sealant group, and fifth generation and seventh generation groups;
whereas, no significant difference was found for sealant retention between seventh
Corresponding author: generation and sealant group at three, six and 12 months.
R. Telgi Lingesha,
Department of Public Health
Conclusion: As separate etch and rinse steps are not required for seventh generation
Dentistry, Kothiwal Dental bonding agents, and almost similar results were obtained for both sealant and seventh
College & Research Centre, generation groups, it can be concluded that application of sealant along with a seventh
Uttar Pradesh, India
generation bonding agent may enhance sealant success and can be used for caries
[email protected] prevention in preventive programs.
Key words: Pit and Fissure Sealants; Dental Caries; Adhesives
Received: 16 March 2015
Accepted: 27 August 2015 (Journal of Dentistry, Tehran University of Medical Sciences, Tehran, Iran (2015; Vol. 12, No. 10)

INTRODUCTION all caries in children, 75% occur in pits and

Dental caries is the most common chronic fissures [3,4].
disease in humans [1]. The World Health Pit and fissure sealants are among the
Organization reports the prevalence of caries promising preventive methods to minimize
in school-aged children to be 60–90% [2]. Of occlusal caries [5]. The cariostatic properties

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Tandon et. al Effect of Adhesive Application on Sealant Success …

of sealants are due to the physical impediment etchant primer and adhesive in a single
of pits and fissures. Fissure sealants were first dispenser) known as self-etching bonding
introduced in 1967 by Cueto and Buonocore agents.
[6] and their effectiveness was recognized by Seventh generation bonding agents, introduced
the American Dental Association in 1971 [7]. in the early 2000s, contain acidic primers and
The anticipated function of a pit and fissure adhesive monomers in a single bottle,
sealant is attained by the adherence of the eliminating acid-etching and rinsing steps and
sealant to the acid etched surface, and thus minimizing the time required for isolation
prevention of food impaction and colonization and ensuring successful bonding [14]. As
of bacteria. As long as the sealant remains only a few studies have compared clinical
intact, the changes of caries development sealant success after the application of
beneath it will be minimal [8]. different bonding agents, the aim of this study
To date, nearly 50 years have passed since the was to compare the effect of fifth and seventh
introduction of pit and fissure sealants to the generation bonding agents on sealant success.
dental market, but the application of sealants
is not as high as expected. This is probably MATERIALS AND METHODS
due to the high failure rate of sealants due to Based on the results of a previous study, a
inadvertent moisture or salivary contam- sample size of 60 children was estimated with
ination. The most common reason for sealant  error=5%,  error=20%, 95% confidence
failure is salivary contamination of etched interval and 80% power [13]. Due to the
surface [9]. Since control of moisture in the longitudinal nature of the study, anticipating
oral cavity is difficult to achieve, placement of the possible dropouts, a sample of 64 school
hydrophilic resin which is not sensitive to children was recruited. All children between
moisture may increase sealant retention. The six-nine years, who fulfilled the inclusion and
first evidence of improved bond strength of exclusion criteria were selected. The inclusion
etched enamel to sealant following the criteria were: Fully erupted bilateral
application of dentine bonding agents in permanent first molar teeth and deep occlusal
presence of moisture or salivary contamination fissures in molar teeth. The exclusion criteria
of enamel was reported by Hitt and Feigal in were: Subjects with one carious or restored
1992 [10]. Other studies confirmed the molar tooth in either side, molar teeth with
advantages of bonding agents applied under their antagonistic teeth missing, uncooperative
sealants on the contaminated enamel to patients or handicapped patients. Written
increase bond strength [11], reduce informed consent was obtained from the
microleakage [12] and enhance the flow of parents or legal guardians of all children and
resin into fissures [13]. the study protocol was approved by the
Sealants were traditionally placed using a fifth Institutional Ethics Review Committee of
generation adhesive system (applied in two Moradabad.
steps of etching followed by adhesive Before starting the evaluation, the examiner
application). was calibrated for recording marginal
As multiple steps were required for the integrity, marginal discoloration, and
application of fifth generation bonding agents, anatomical form and kappa co-efficient for
it would increase chair side time, patient intra-examiner reliability ranged between 0.80
discomfort and risk of salivary contamination. - 0.90.
To minimize these drawbacks, seventh Each of the 64 children received sealants in
generation bonding agents were introduced, four permanent molars in a split mouth design,
which were applied in one step, (having such that each child received sealant in a

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Journal of Dentistry, Tehran University of Medical Sciences Tandon et. al

permanent first molar with fifth generation Adjustment of the occlusion was done with a
bonding agent (Prime and Bond NT, micromotor headpiece and finishing burs.
DENSTPLY) in one arch and seventh Sealant retention was checked with the help of
generation bonding agent (Xeno V, Dentsply, an explorer. The evaluation was carried out at
Konstanz, Germany) in the other arch, and baseline, three months, six months and 12
contra-lateral molars were sealed with sealant months according to the criteria given by
alone (Delton FS, Dentsply, Konstanz, Feigal et al, in 2000 [15].
Germany). Parents were verbally reminded via phone
Sealant was placed in such a manner that out calls about the next follow up and instructions
of 256 teeth, sealant along with fifth were given to all the study subjects for the
generation bonding agent was placed on 64 maintenance of oral hygiene.
teeth i.e., 16 maxillary right molars, 16 Statistical analysis was carried out using SPSS
maxillary left molars, 16 mandibular right version 16.0 (SPSS Inc., Chicago, IL, USA)
molars and 16 mandibular left molars. and the data were analyzed by Chi-square test
Similarly, 64 teeth were sealed with sealant at P<0.05 level of significance.
along with seventh generation bonding agent
and the remaining 128 contra-lateral teeth RESULTS
were sealed with sealant alone (split mouth A total of 64 children who fulfilled the
design). inclusion and exclusion criteria were recruited
The technique used for teeth sealed with in the study. Dropouts were three, five and
sealant alone was as follows: the slow-speed, three children at three, six and 12 months,
dry-brush cleaning of the surface; moisture respectively. Out of 64 school children, 38
control using cotton rolls and salivary ejector; were males and 28 were females; there was no
30 seconds of acid etching (37% H3PO4 gel); statistically significant difference between
washing with air-water spray for 20 seconds; males and females in sealant loss (anatomical
air-drying and finally placement of sealant form) in the three groups at three, six and 12
followed by 40 seconds of light months. A total of 128 teeth were sealed with
polymerization. Whereas technique used for sealant alone; out of which, 12 teeth had
teeth sealed with sealant along with fifth fluorosis and 116 teeth did not have fluorosis;
generation bonding agent was as follows: while 64 teeth received sealant along with fifth
After etching and drying, a layer of fifth generation bonding agent; out of which, six
generation bonding agent was applied to the teeth had fluorosis and 58 did not. Of the
surface with a hand-held brush; this layer was remaining 64 teeth that received sealant along
then air-thinned and sealant was applied with seventh generation bonding agent, six
followed by 40 seconds of light polymer- teeth had fluorosis and 58 did not.
ization. Statistically, no significant difference was
Technique used for teeth which are sealed found in sealant loss (anatomical form)
with sealant along with seventh generation between the teeth with and without fluorosis in
bonding agent was as follows: after cleaning each group at three, six and 12 months (Table
of the surface, moisture control was done 1). Comparison of anatomical form among all
using cotton rolls and salivary ejector; a layer the groups at three, six and 12 months
of seventh generation bonding agent was revealed statistically significant differences
applied to the surface with a hand-held brush; between fifth and seventh generation and fifth
this layer was then air-thinned and sealant was generation and sealant groups while no
applied followed by 40 seconds of light significant difference was found between
polymerization. seventh generation and sealant group.

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 Tandon et. al Effect of Adhesive Application on Sealant Success …

Statistically, no significant difference was ability of sealant to adhere to micro-retentive

found for marginal discoloration and marginal grroves on tooth surfaces, having a surface
integrity among all the three groups at three, energy less than that of free surface energy of
six and 12 months (Table 2). There was no the substrate [18,19].
statistically significant difference between Priming the etched enamel with a dentin-
baseline and three months, three and six bonding agent prior to placement of a sealant
months and six and 12 months among the fifth can increase surface wettability and contact of
generation, seventh generation and sealant sealant and the substrate by removing
groups in this respect (Table 3). contaminants [20].
In the current study, evaluation criteria of
DISCUSSION Fegial et al. [15] was considered to record
Pit and fissure sealants have been accepted as marginal Integrity, marginal discoloration and
an effective caries prevention method [16]. anatomical form. Marginal discolorstion
The sealant application is highly technique occurs when there is marginal breakdown,
sensitive and salivary contamination is the creating a rough and irregular surface. This
most common factor decreasing the success can act as a niche for the accumulation of
rate of sealants; insufficient etching, plaque and food debris and also promote the
entrapment of air bubbles in the sealant penetration of oral fluids and cause
material and incomplete removal of debris microleakage, so as that of anatomical form
from the pits and fissures before the etching (retention). Anatomical form indicates the
process can also compromise sealant success morphology of tooth where the sealant was
[3]. Acid etching is the most critical step in placed. In the current study, out of 64 children
sealant application. Salivary contimation prior six had mild fluorosis; whereas the remaining
to sealant placement will cause adherence of 58 did not. When comparing sealant retention
salivary proteins to the etched enamel leading (anatomical form) between fluorotic and non-
to remineralization of enamel, which will fluorotic teeth, no statistically significant
interfere with sealant penetration and thereby difference was seen.
reducing the bond strength of sealant [17]. This result is in agreement with that of Isci et
To prevent salivary contamination of the al, in 2010; they found no statistically
etched enamel, hydrophilic resins were added significant difference in sealant retention
to sealants, which are insensitive to salivary between mild fluorotic and non-fluorotic teeth
contamination and also decrease the viscosity [21]. This might be due to no change in the
of adhesive. A low-viscosity adhesive spread prismatic structure of enamel in non-fluorotic
uniformly over a tooth surface increases the and mild fluorotic teeth after etching.

Table 1. Comparison of sealant loss (anatomical form) between teeth with and without fluorosis at three months, six
months and 12 months.

Fluorotic Non fluorotic 3 months 6 months 12 months

Teeth (F) Teeth (NF)
(%) (%) F(%) NF(%) P F(%) NF(%) P F(%) NF(%) P

Sealant alone 0/12 0/116 1/10(0.1) 2/112(0.01) 0.228 1/10(0.1) 3/108(0.02) 0.302 1/10(0.01) 3/112(0.02) 0.293
(N=128)
th
5 Generation 0/6 0/58 2/5(0.4) 4/56(0.07) 0.071 2/5(0.4) 5/54(0.09) 0.102 2/5(0.4) 5/56(0.08) 0.096
(N=64)
7th Generation 0/6 0/58 1/5(0.2) 1/56(0.01) 0.159 1/5(0.2) 1/54(0.01) 0.164 1/5(0.2) 1/56(0.01) 0.159
(N=64)

*Chi square test at P<0.05 level of significance

**Dropout of 3, 5 and 3 patients at 3, 6 and 12 months, respectively.

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 Journal of Dentistry, Tehran University of Medical Sciences Tandon et. al

Table 2. Comparison of marginal discoloration, marginal integrity and anatomical form among the groups at three, six and 12 months.

3 months 6 months 12 months

Total
Total Total
numb Marginal Marginal Anatomical Marginal Marginal Anatomical Marginal Marginal Anatomical
number number
er of discoloration integrity form discoloration integrity form discoloration integrity form
of teeth of teeth
teeth

5th Generation 61 1 3 6 59 2 3 7 61 2 4 7

7th Generation 61 0 1 2 59 0 1 3 61 2 2 3

Sealant 122 0 1 3 118 1 1 3 122 1 1 4

5th vs 7th
P=0.315 P=0.309 P=0.042(S) P=0.362 P=0.361 P=0.039(S) P=1 P=1 P=0.041(S)
Generations

5th Generation
P=0.156 P=0.074 P=0.049(S) P=0.320 P=0.168 P=0.041(S) P=0.217 P=0.217 P=0.035(S)
vs Sealant

7th Generation
P=1 P=0.615 P=0.606 P=0.478 P=0.286 P=0.222 P=0.217 P=0.217 P=0.741
vs Sealant

S: significant

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 Tandon et. al Effect of Adhesive Application on Sealant Success …
In the current study, the teeth with severe Although not contraindicated, due to some
fluorosis were excluded, because to obtain the clinical limitations such as being time
same etching pattern as that of normal enamel, consuming, cost effectiveness and doubtful
the etching time should be increased for up to retention, routine use of a fifth generation
120 to 180 seconds, as fluorapetite crystals are bonding agent as part of sealant application
acid resistant, whereas in mild fluorosis the technique is not recommended. Unlike the
usual etching time would suffice (30 seconds). fifth generation, we can cut short the cost and
The fifth generation bonding agent is the most time by using seventh generation bonding
commonly used bonding agent [15]. agent for sealants as the etching and rinsing
We tested the fifth generation bonding agent steps are skipped; it increases patient comfort,
(Prime and Bond NT), which has a unique reduces chairside time, decreases contamin-
combination of PENTA chemistry and ation, and increases the efficacy of resin
nanofiller particles. restoration [24]. Seventh generation bonding
PENTA forms a chemical bond to tooth agents also known as self-etch adhesive
calcium which provides a unique combination bonding agents perform etching, disinfecting,
of micromechanical and chemical bonding desensitizing, priming and bonding all in a
along with a modulus of elasticity that single step. We considered tert-Butanol and
improves marginal seal, minimizes functionalized phosphoric acid ester as a basic
postoperative sensitivity and protects against constituent of bonding agent. Tert-Butanol is a
secondary caries. solvent with a well-balanced polarity; it uses
The results of our study indicated that the acrylic amide resin, which makes the
application of fifth generation bonding agent formulation less susceptible to hydrolysis in
prior to fissure sealant did not increase the aqueous form. This bonding agent uses
retention rate at the end of one year, which inverse functionalized phosphoric acid esters
was similar to the result of studies done by that have a hydrolysis-stable ether bond.
Ansari and Hashemi [20] and Boksman et al Exclusive bond durability of self-etch (Xeno
[22]. V) adhesive lies in the fact that much of the
However, an evidence-based study by Locker calcium is available for the additional
et al, in 2003 concluded that application of a chemical interactions with specific adhesive
bonding agent prior to the sealant use does not monomers as all of the hydroxyapetites are not
appear to enhance retention rates [23]. removed from the interaction zone.

Table 3. Comparison of sealant retention at different time intervals.

Baseline Baseline - 3 months 3 months - 6 months 6 months - 12 months

Total Total Total Total

number number Loss (%) P-value number Loss (%) P-value number Loss (%) P-value
of teeth of teeth of teeth of teeth

5th
64 61 6 (9.84) 0.145 59 1 (2.06) 0.721 61 0 (0) 0.947
Generation

7th
64 61 2 (3.3) 0.319 59 1 (0.1) 0.973 61 0 (0) 0.973
Generation

Sealant 128 122 3 (2.5) 0.563 118 0 (0) 0.668 122 1 (0.7) 0.962

*Chi square test at P<0.05 level of significance

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Journal of Dentistry, Tehran University of Medical Sciences Tandon et. al

Therefore, bonds are stable, even in the difficult to achieve, therefore application of a
aqueous environment and this mechanism is hydrophilic bonding agent, which is
supposed to protract the clinical service of insensitive to moisture may increase the
restorations [25]. Also, self-etch adhesives sealant retention. As etch and rinse steps are
prevent the hydrolysis of collagen and thus not required separately for a seventh
decrease the early degradation of bonds. generation bonding agent, application of
The limited technique sensitivity combined sealant in large-scale caries prevention
with simple and time saving application programs may be quite easy, affordable and
method as well as eliminating the rinsing step successful. Further in-vivo long-term follow
render sealant placement along with a seventh up studies should be conducted on a
generation bonding agent a true alternative heterogeneous population to compare sealant
especially in children. In the current study, the success using different adhesive systems.
frequency of anatomical form (sealant
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