5th Grade Preventive dentistry Lec.

15

Assis. Lec. Shahad Jamal

Pit and fissure sealants

Fissure sealant can be defined as “a material that is introduced into the occlusal
pits and fissures of caries susceptible teeth, thus forming a micromechanically or
chemically bonded, protective layer cutting access of caries-producing bacteria
from their source of nutrients.”

Pit-and-fissure sealants is a material flowed over the occlusal surface of the tooth
where it penetrates the deep fissures to fill areas that cannot be cleaned with the
toothbrush, the hardened sealant presents a barrier between the tooth and the
hostile oral environment.

Placement of sealants is a non-invasive technique (used both as primary and

secondary preventive measures against occlusal caries) that maintains tooth
integrity through the caries active period and will at least delay the need for an
occlusal restoration until proximal lesion develops.

Historically

Several agents have been tried to protect deep fissures on occlusal surfaces:
In 1895, Wilson reported the placement of dental cement in pits and fissures to
prevent caries. In 1929, Bodecker suggested that deep fissures could be broadened
with a large round bur to make the occlusal areas more self-cleansing, a procedure
that is called enameloplasty. Two major disadvantages, accompany enameloplasty.

First, it requires a dentist, which immediately limits its use.

Second, in modifying a deep fissure by this method, it is often necessary to remove
more sound tooth structure than would be required to insert a small restoration.
In 1923 and again in 1936, Hyatt advocated the early insertion of small restorations
in deep pits and fissures before carious lesions had the opportunity to develop. He
termed this procedure prophylactic odontotomy. Again, this operation is more of a
treatment procedure than a preventive approach, because it requires a dentist for
the cutting of tooth structure.

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Several methods have been unsuccessfully used in an attempt either to seal or to

make the fissures more resistant to caries. These included the use of topically
applied zinc chloride and potassium ferrocyanide and the use of ammoniacal silver
nitrate; they have also included the use of copper amalgam packed into the
fissures.

A final course of action to deal with pit-and-fissure caries is one that is often used:
do nothing; wait and watch. This option avoids the need to cut good tooth structure
until a definite carious lesion is identified. It also results in many teeth being lost
when individuals do not return for periodic exams

The major event that made resin pit and fissure sealants possible came from the
early work of Buonocore (1955) who earned the title of being the “Father of
Adhesive Dentistry” by introducing the acid etch and bonding technique for resin-
based materials. The purpose of his original research was the development of a
sealant to prevent occlusal caries on posterior teeth. In the 1960s, Bowen converted
them to an entirely acceptable restorative group by introducing bis- GMA and
including a variety of fillers for physical reinforcement and control of setting
shrinkage. Bisphenol A-Glycidyl Methylacrylate (Bis-GMA) Sealants is now the
sealant of choice.

In the same time period, Smith recognized the biological benefits of the
polyalkenoic acid group and combined these with zinc oxide to develop the
polycarboxylate cements, which was the first group of materials to have both self-
adhesion and fluoride-releasing capabilities. Wilson and others (1985) modified
this through the use of a powdered glass instead of zinc oxide and thus introduced
glass-ionomer cements, which exists today as both restorative and preventive
materials.

Development of occlusal caries

Caries affecting pit and fissures are the first types of lesions encountered in
children. In addition to general risk factors, the following three site-specific risk
factors are associated with the development and progression of occlusal caries

1. Morphology of pit and fissure systems

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2. Eruption stage
3. Functional use

Criteria for Selecting Teeth for Sealant Placement

Previously routine application of sealant was recommended for all posterior deep
occlusal fissure, fossa or lingual pit present in teeth because it was believed to be
the only realistic way to prevent occlusal decay, but now sealants should only be
applied to patients and placed in teeth after careful clinical judgment of the
individual, it needs to be considered in the context of risk factor both for individual
patients and for individual teeth

   Thus, teeth in caries-free patient and caries-free occlusal surfaces,

which have been fully erupted for more than 2 years, do not need application
of sealant. (Newly erupted tooth with its first year of eruption).
   While where caries has affected one or more permanent molar teeth,
(and those who have experienced of caries in primary teeth) the remaining
sound fully erupted pits and fissure should be sealed

Therefore the decision to place sealant on sound teeth based on :

 Oral hygiene of the patient

 Individual history of dental caries
 Dietary habits
 Patient cooperation and reliability in keeping recall appointments
 Tooth type and tooth morphology(fissure morphology: V, U, Y, I, IK types.

Because the time from tooth emergence to full occlusion is the most critical period
for caries initiation (Eruption stage, Functional use) adequate timing of sealant
application is important.

The duration of the eruption period is a further risk factor. So teeth with longer
eruption time tend to have more occlusal caries. For example, occlusal caries is
much more prevalent in molars, which have a relatively long eruption time of 12 to
18 months, compared to premolars, with an eruption time of only a few months

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If the risk factors outlined above are identified in-patient then it is prudent to seal
all susceptible sites on permanent teeth as soon after eruption as is practicable.
Because no harm can occur from sealing, when in doubt seal and monitor

A sealant is probably indicated if:

   The fossa (shallow depression) selected for sealant placement is well

isolated from another fossa with a restoration.
   The area selected is confined to a fully erupted fossa even though the
distal fossa is impossible to seal because of inadequate eruption.
   The selected tooth has an intact occlusal surface when the contralateral
tooth surface (surface of tooth in opposite arch) is carious or restored; teeth
on opposite sides of the arches usually are equally prone to caries.
   An incipient lesion exists in the pit‐and‐fissure area.
   Sealant material can be flowed over a conservative class I composite or
amalgam to improve the marginal integrity and into the remaining pits and
fissures to prevent further recurrent decay. Concerning the teeth of the adult,
the sealant should be placed if there is evidence of existing or impeding
caries susceptibility as would occur following excessive intake of sugar or as
a result of a drug or radiation induced xerostomia.

In all cases it’s the disease susceptibility of the tooth should be considered
when selecting teeth for sealants, not the age of the individual
A sealant is contraindicated under these circumstances:

o  Patient behavior does not permit use of adequate dry field

techniques throughout the procedure.
o   An open, frank, carious lesion exists on the same tooth.
o   Caries exist on other surfaces of the same tooth in which
restoration will disrupt an intact sealant.
o   A large occlusal restoration is already present

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Ideal sealants materials

The desired clinical outcomes from the use of sealants are to prevent the
establishment and stop the progression of carious lesions. the technique must
provide good retention, a long-term seal and be non-technique sensitive. The
requirements of an ideal material include biocompatibility low viscosity low
solubility esthetically acceptable and visible to facilitate reassessment.

There are two main types of materials that can be used as sealants:

 Unfilled or lightly filled composite resins

 Glass ionomers.

Neither of these can be regarded as ideal so the selection of which material to use
will be driven by the requirements of each case

Requisites for Sealant Retention

Placement of pit and fissure sealants is technique sensitive. For sealant retention
the surface of the tooth must:

1) have a maximum surface area sealants do not bond directly to the teeth. Instead,
they are retained mainly by adhesive forces. The surface area is greatly increased
by the acid etch, which in turn increases the adhesive potential

2) have deep, irregular pits and fissures (Deep, irregular pits and fissures offer a
much more favorable surface contour for sealant retention compared with broad,
shallow fossae. The deeper fissures protect the resin sealant from the shear forces
occurring as a result of masticatory movements. Of parallel importance is the
possibility of caries development increasing as the fissure depth and slope of the
inclined planes increases. Thus, as the potential for caries increases, so does the
potential for sealant retention).

3)  be clean

4)  be absolutely dry at the time of sealant placement and uncontaminated with
saliva residue.

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Sealant Placement Guidelines

Step 1: Prepare the Teeth (Surface Cleanliness): The need and method for cleaning
the tooth surface prior to sealant placement are controversial. Usually the acid
etching alone is sufficient for surface cleaning, however, it was shown that
cleaning teeth with the prophylaxis pastes with or without fluoride did not affect
the bond strength of sealants. However all heavy stains, deposits, debris, and
plaque should be removed from the occlusal surface before applying the sealant.

Step 2: Isolate the Teeth: Adequate isolation is the most critical aspect of the
sealant application process. Salivary contamination of a tooth surface during or
after acid etching will have a deleterious effect on the ultimate bond between
enamel and resin. A dry field can be maintained in several ways, including use of a
rubber dam, employment of cotton rolls, and the placement of bibulous pads over
the opening of the parotid duct.

The rubber dam provides an ideal way to maintain dryness for an extended time
Some of the disadvantages of Rubber dam include: discomfort during clamp
placement, need for local anesthetic in some instances, difficulty in securely
placing a clamp onto a partially erupted tooth, also it is not feasible to apply the
dam to the different quadrants of the mouth; instead it is necessary to employ
cotton rolls, combined with the use of an effective high-volume, low-vacuum
aspirator. Cotton roll holders may be used. If a cotton roll does become slightly
moist, another short cotton roll can be placed on top of the moist segment and held
in place for the duration of the procedure.

In the event that it becomes necessary to replace a wet cotton roll, it is essential
that no saliva contacts the etched tooth surface; if there is any doubt, it is necessary
to repeat all procedures. This includes a 15-second etch to remove any residual
saliva.

Step 3: Dry the Surfaces: Dry teeth with air for 20–30 seconds, Check to make
sure there is no moisture coming out of air syringe tip.

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Step 4: Etch the Surfaces (Increasing the Surface Area): An etchant of 37%
phosphoric acid is applied for 20 seconds on the occlusal surface prior to the
placement of the sealant, another 15 seconds of etching is indicated for fluorosed
teeth to compensate for the greater acid resistance of the enamel.

One should always apply the etchant onto all the susceptible pits and fissures of the
tooth and extend it up the cuspal inclines well beyond (at least 2 millimeters) the
anticipated margin of the sealant. If any etched areas on the tooth surface are not
covered by the sealant or if the sealant is not retained, the normal appearance of the
enamel returns to the tooth within 1 hour to a few weeks due to a remineralization
from constituents in the saliva.

The etchant may be either in liquid or gel form. The former is easier to apply and
easier to remove.

• If using a gel: applied with a supplied syringe and left undisturbed for all of time

• If using a liquid: is placed on the tooth with a small resin sponge or cotton
pledged held with cotton pliers. Continue to apply etchant throughout the etchant
time. Both are equal in abetting retention

Step 5: Rinsing and Drying the Teeth: For 10 seconds the water from the triple
syringe is flowed over the occlusal surface and hence into the aspirator tip. Then
the surface is dried for 10 seconds. The air supply needs to be absolutely dry.

The dried tooth surface should have a white, dull, frosty appearance. If there are
areas at or near the opening of the pits and fissures that do not have the frosty look,
then etch again

The teeth must be dry at the time of sealant placement because sealants are
hydrophobic. The presence of saliva on the tooth is even more detrimental than
water because its organic components interpose a barrier between the tooth and the
sealant.

Whenever the teeth are dried with an air syringe, the air stream should be checked
to ensure that it is not moisture-laden. A check for moisture can be accomplished
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by directing the air stream onto a cool mouth mirror; any fogging indicates the
presence of moisture. Possibly the omission of this simple step accounts for the
inter-operator variability in the retention of fissure sealants.

Step 6: Application of Sealant Material: With either the light-cured or

autopolymerized sealants, the material should first be placed in the fissures where
there is the maximum depth. At times penetration of the fissure is negated by the
presence of debris, air entrapment, narrow orifices, and excessive viscosity of the
sealant. The sealant should not only fill the fissures but should have some bulk
over the fissure. After the fissures are adequately covered, the material is then
brought to a knife edge approximately halfway up the inclined plane. Following
polymerization, the sealants should be examined carefully before discontinuing the
dry field. If any voids are evident, additional sealant can be added without the need
for any additional etching.

Step 7: Evaluate the Sealant: The finished sealant should be checked for retention
without using undue force. In the event that the sealant does not adhere, the
placement procedures should be repeated, with only about 15 seconds of etching
needed to remove the residual saliva before again flushing, drying, and applying
the sealant.

If two attempts are unsuccessful, the sealant application should be postponed until
remineralization occurs. The occlusion should be checked visually or, if indicated,
with articulating paper. Usually any minor discrepancies in occlusion are rapidly
removed by normal chewing action. If the premature contact of the occlusal
contact is unacceptable, a large round cutting bur may be used to rapidly create a
broad resin fossa.

Resin sealants are retained better on recently erupted teeth than in teeth with a
more mature surface

They are retained better on first molars than on second molars.

They are better retained on mandibular than on maxillary teeth. This latter finding
is possibly caused by the lower teeth being more accessible, direct sight is also
possible; also, gravity aids the flow of the sealant into the fissures. Teeth that have
been sealed and then have lost the sealant have had fewer carious lesions . This is

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possibly due to the presence of tags that are retained in the enamel after the bulk of
the sealant has been sheared from the tooth surface.

Step 8: Re-evaluation: Because the most rapid fall off of sealants occurs in the
early stages(probably caused by faulty technique in placement), an initial 3-month
recall following placement should be routine for determining if sealants have been
lost then evaluated on a six months basis as sealant losses probably being due to
abnormal masticatory stresses. After a year or so, the sealants become very
difficult to see or to discern tactilely, especially if they are abraded to the point that
they fill only the fissures.

Fluoride‐Releasing Sealants

Use of a fluoridated resin‐based sealant was thought to possibly provide an

additional anticariogenic effect. Fluoride is added to sealants by two methods. The
first method involves adding a soluble fluoride to the unpolymerized resin. The
second method involves adding an organic fluoride compound that will bind
chemically to the resin to form an ion exchange resin. Fluoride‐releasing sealants
have shown antibacterial properties as well as greater artificial caries resistance
compared with a nonfluoridated sealant.

Glass ionomer sealants

The main advantage of the glass-ionomer cement is

 Its ability to chemically adhere to the tooth surface with minimal

preparation as the acid used is, Polyacrylic acid .This diluted version does not
etch the enamel but rather prepares it by increasing surface energy to improve
wetting of the glass-ionomer sealant and improve adhesion.

 Anti-caries effect that can be attributed to both long-term fluoride release

and recharge

 Is a water-based material and is more technique tolerant so should be

considered when:

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● Four-handed dentistry is not available

● Lack of patient’s full co-operation
● There is bleeding or gingival fluid seepage
● Moisture control is compromised

Glass ionomer is best suited for protecting erupting teeth when it is inserted under
the operculum.

Colored Versus Clear Sealants

Both clear and colored sealants are available. They vary from translucent to white,
yellow, and pink. The selection of a colored versus a clear sealant is a matter of
individual preference. The colored products permit a more precise placement of the
sealant, with the visual assurance that the periphery extends halfway up the
inclined planes. Retention can be more accurately monitored by both the patient
and the operator placing the sealant.

On the other hand, a clear sealant may be considered more esthetically acceptable.
On the other hand, some clinicians seem to prefer the clear sealants because it is
possible to see under the sealant if a carious lesion is active or advancing.

Light-Cured Versus Self-Cured Sealants

type advantage disadvantage

self-cure sealant 1. Simple to use 1. Once mixing has started, the operator must
2. Less expensive—does not require continue mixing and immediately place the sealant,
additional equipment or stop and make a new mix if a problem should
occur.
2. The catalyst and base must be mixed prior to
placement, increasing the chance of incorporating air
bubbles into final product
light- cure 1. Operator has control over the initiation 1. Requires extra-piece of equipment that can break
sealant of polymerization down.
2. Supplied as single liquid so no mixing 2. High cost of curing light and shorter shelf-life of
material.

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