PIT AND FISSURE SEALANTS

BY : PALKI BANSALPG FIRST YEARMODERATOR

DR. KAVITA

REFERENCES:- Pediatric dentistry Infancy through

Adolescence. 5th edition by: CASAMASSIMO. 2013

Richard J. Simonsen.Pit and fissure sealant: review of literature. Pediatr Dent. 2002;24(5):393-414

James J.C, Kevin J.D.Dental sealants guidelines development: 2002-2014. Pediatr Dent 2015;37(2):111-5

Essentials of preventive and community dentistry. 4th edition by Soben Peter.2010

Material that is introduced into the occlusal pits and fissures of caries-susceptible teeth, thus forming a

micromechanically bonded, protective layer, cutting access of caries-producing bacteria from their source of nutrients.

(Simonsen RJ 2002 )

PIT AND FISSURE

SEALANT

PITS small pinpoint depressions located at the junction of developmental grooves or at terminals of those grooves.

(Ash and Nelson)  FISSURE:

Deep clefts between adjoining cusps. These defects occur on occlusal surfaces of the molars and premolars, with tortuous configurations that are difficult to assess from the surfaces. (Orbans)

Approximately 90% of the caries in permanent teeth of children occurs in pits and fissure, and approximately two- thirds of caries are on the occlusal surface alone.

Similarly, the pits and fissures of primary teeth are also at risk because roughly 44% of carious lesion in the primary teeth affect the occlusal surfaces of molars.

Centres for disease control and prevention: national health and nutrition examination surveys 1994-2004

Why fissures are caries susceptible????

1.NEWLY ERUPTED, IMMATURE TOOTH ENAMEL HIGH ORGANIC CONTENT, MORE PERMEABLE CARIES SUSCEPTIBLE

2. FISSURE MORPHOLOGY PROVIDE ENVIRONMENT FOR PLAQUE RETENTION AND BACTERIA PROLIFERATION.3.ENAMEL IN PIT N FISSURES THINNER ACCELERATED DEMINERALISATION

MORPHOLOGY OF PIT & FISSURES

1. V – Type (34%)

2. U – Type (14%)

3. I – Type (19%)

4. IK – Type (26%)

5. Inverted Y – Type (7%)

Nagano(1961) described following principal types of fissures, based on the alphabetical description of shape:

•Shallow, wide V & U shaped fissures – a. self cleansing b. somewhat caries resistant.•Deep, narrow I shaped fissure – a. quite constricted b. resemble bottle neck c. narrow slit like opening d. large base which extends towards DEJ e. caries susceptible.•K- shaped fisssures – a. susceptible to caries

DIAGNOSIS OF PIT & FISSURE CARIES:

In 1968, at an ADA sponsored conference on clinical testing of cariostatic agents  the criteria for detection and diagnosis of pit & fissure lesions were defined as follows :

Caries is present when the explorer catches or resists removal after insertion into a pit or fissure with moderate to firm pressure and when this is accompanied by one or more of the following signs of caries:

a)   Softness at base of the area.

b) Opacity or loss of normal translucency adjacent to a pit or fissure as evidence of undermining or demineralization.

c)   Softened enamel adjacent to the pit or fissure that can be scraped away with the explorer.

In 2005 Stookey , challenged that long held belief that probing an occlusal groove with an explorer does not increase dentists ability to make correct diagnosis and forceful use of explorer can actually damage the tooth.

In 2008, evidence based recommendations published state that “ th use of explorers is not necessary for the detection of early lesions”. Visual examination alone is sufficient to detect early lesions.

HISTORY OF PIT AND FISSURE SEALANTS

In1905 Miller used silver nitratre. In 1923, Hyatt reported a technique

termed “Prophylactic Odontomy” in which non –carious fissures were prepared and restored with a silver alloy as a prophylactic measure.

1929,Bodecker initially introduced an alternate method for caries prevention, FISSURE ERADICATION.

In 1955, Buonocore described the technique of acid etching as a simple method of increasing the adhesion of self- curing methyl methacrylate resin material to dental enamel.

The first paper published on subject of pit and fissure sealant was in 1965 by Cueto and Buonocore.

First pit and fissure sealant 1971 named Nuva-seal( LD. Caulk, Milford. Del.) INTRODUCED.

First coloured sealant 1976, concise white sealant by 3m company.

TYPES OF PIT & FISSURE SEALANTS

1…ACCORDING TO CHEMICAL STRUCTURES OF MONOMERS

MMA – Methyl methacrylate TEGDM – Tri ethylene glycol

dimethacrylate BPD – Bis phenol dimethacrylate Bis GMA – Reaction product of Bis

phenol A & glycidyl methacrylate with a methyl methacrylate monomer.

ESPE monomer PMU – Propyl methacrylate urethane

2…BASED ON GENERATIONSA) FIRST GENERATION SEALANTS

-- UV light. eg:Nuva-lite

B) SECOND GENERATION SEALANTS-- self cure/ chemical cure. eg: Concise

white.

C) THIRD GENERATION SEALANTS-- light cured/ visible ( blue) light.

eg:Helioseal.

D) FOURTH GENERATION SEALANTS-- fluoride releasing sealants. eg: Seal

right (Pulodent)

3. BASED ON FILLER CONTENT

• UNFILLED -- better flow-- more retention-- abrade easily

• FILLED-- resistance to wear

-- may need occlusal adjustments

4. BASED ON COLOR CLEAR

TINTED/OPAQUE

COLOURED

5.Based on curing AUTOPOLYMERISING LIGHTCURE

Indications:

3. No radiographic or clinical evidence of interproximal caries .

4. Possibility of adequate isolation from salivary contamination.

1. Stained pits and fissures with minimum appearance of decalcification or opacification.

2. Deep, retentive pits and fissures, which may cause wedging or catching of an explorer.

Contraindications:1. Well-coalesced, self-cleansing pits and fissures.

2. Radiographic or clinical evidence of interproximal caries in need of restoration.

3. Tooth partially erupted and no possibility of adequate isolation from salivary contamination.

4. Life expectancy of tooth is limited.

5. Lack of preventive practices.

ELIGIBILITY FOR SEALANT APPLICATION:SELECTION OF PATIENT:-

2.BASED ON CLINICAL JUDGEMENT:

Age Oral hygiene Familial and individual

history of dental caries Fluoride environment and

history Dietary habits Tooth type and morphology

1.BASED ON AGE:

3-4 years of age for the primary molar sealant application.

6-7 years of age for the first permanent molar.

11-13 years of age for the second permanent molars and the premolars.

3.BASED ON CARIES RISK:

Simonsen in 1983

Group 1: Caries-free patients judged at no risk to decay.

Group 2: Patients judged to be at moderate risk to decay.

Group 3: Patients with rampant caries at a high risk to decay.

STEPS OF SEALANT APPLICATION

ASSEMBLE ARMAMENTARIUM

Position patient Mandibular

Maxillary

1.Isolation of tooth:

The tooth should be isolated from salivary contamination by use of rubber dam or by cotton rolls and suctioning.

Silverstone concluded that salivary contamination allows rapid precipitation of glycoprotein's onto the etched

enamel, greatly decreasing the bond strength.

Buonocore(1971) reported good retention of the sealant with cotton roll rather than rubber dam isolation.

2.Tooth preparation:

Tooth surface is cleaned to remove plaque and debris from the

enamel and pit and fissures of tooth. The early application technique - pumice

and water mixture using a rotary brush Various other cleaning methods have

been tested. One is the Prophy-Jet, an early air abrasion system.

The tensile bond strength of sealants prepared with various techniques was measured in a study by De Craene et al.,1989

Air polishing with the Prophy-Jet followed by acid etching produced the highest bond strength of all groups tested.

A statistically significant higher mean bond strength was found after air polishing and acid etching compared to no cleansing prior to acid etching.

Invasive technique Garcia-Godoy and de Araujo,1994

demonstrated that the Enameloplasty Sealant Technique (EST) allows a deeper sealant penetration and a superior sealant adaptation than the conventional sealant treatment without any mechanical enlargement of the fissures with a bur.

An increased surface area for sealant retention is readily evident in all samples treated with the EST.

In another study, superior sealants were obtained when tooth surfaces were prepared by a bur, compared to air abrasion and conventionally prepared surfaces.(Wright et al,1999).

Enameloplasty reduces microleakage of pit and fissure sealants, especially when load is applied to teeth, irrespective of which bur is used to enlarge the fissure. The application of occlusal force to the tooth produces significantly more microleakage, unless enameloplasty is performed.(Zervou et al,2000)

Koh et al,1998, showed that exposure of enamel to NaF, SnF2 or APF prior to placement of unfilled or filled sealants has no effect on in vitro bond strength between the enamel and the sealants.

Koh et al in 1995 showed that topical fluoride treatment has no clinical effect on retention of pit and fissure sealants.

3.Acid etching tooth surface: Silverstone in 1975 identified 3

basic patterns of etching:

Type 1:Generalised roughening of enamel surface, but with distinct hollowing of prism centers and relatively intact peripheral regions.

Type 2:Prism peripheries appear to be damaged. Prism cores are left projecting towards original enamel surface.Type 3:Show neither type 1 or 2 etching pattern but appear as generalised surface roughening.

Buonocore 1955, initially used 85% phosphoric acid for 60 seconds for etching enamel. In the early 1970s, it was believed that,

due to the “prismless” nature of primary enamel, it would require double the etching time of permanent enamel, and this became the standard clinical procedure.

Primary enamel has been described as “prismless” by Gwinnett, 1973 . However, there is no evidence of prismless enamel (which would require a longer etching time) on occlusal surfaces (it is mostly found in cervical regions).

Despite this, early recommendations for etching primary enamel were twice then-accepted time for permanent enamel (120 seconds vs 60 seconds).(Silverstone and Dogon 1976).

The first report comparing the retention on primary molars of the 120-second etching time vs 60 seconds showed no difference in sealant retention. (Simonsen,1978)A later report noted that, “Decreasing the etch time for primary molars has been found to decrease the chance of contamination, during etching. Additionally , the shorter etch time was far more acceptable to 3- and 4-year-old children.” (Simonsen,1979)

Silverstone(1974) found that 60 sec application of unbuffered solution of 37% phosphoric acid produced the most favourable conditions for bonding.

Fuks et al(1984) and Eidelman et al(1984) showed respectively that a 20 sec etch provided similar resistance and retention rates when compared to a 60 sec etch.

The most accepted times were given in IADR sealent symposium in 1991:

 

Primary teeth 30 secs.

Permanent teeth 20 secs.

4.Rinse and dry etched tooth surface:

Tooth is washed with water for about 30 seconds to remove all the etchant and then air-dried for 15 seconds with uncontaminated compressed air.

A properly etched tooth surface has a dull frosted appearance.

5.Use of intermediate bonding layer:

Isolation is the key to the success of the clinical sealant procedure.

Salivary contamination, unless washed off thoroughly (and as some would do, re etch the area) leads to significantly reduced bond strengths.

Feigal, came up with the novel concept that hydrophilic bonding materials that contain water, may, when applied under a sealant, minimize the bond strength normally lost when a sealant is applied in a moist environment.

Bonding agent under sealant on wet contamination yielded bond strengths equivalent to the bond strength obtained when sealant was bonded directly to clean, etched enamel. Bonding agent used without contamination yielded bond strengths significantly greater than the bond strength obtained when using sealant alone without contamination. (Feigal and Hitt,1992)

Retention and microleakage have shown improvement when a bonding agent is used: A 2-year clinical study comparing sealants done with intentional salivary contamination shows that sealant retention is possible on wet enamel if a bonding agent is used between enamel and sealant.(Chestnutt et al,1994)

In primary teeth, the effect of bonding agents on the microleakage and bond strength of sealant has been studied. The use of enamel-dentin bonding agents under sealant in moisture-contaminated conditions gave better results than applying sealant alone onto non contaminated teeth(Tolunoglu et al,1999)

Boksman(1993) carried out a clinical trial of sealants with and without bonding agent and found no benefit to the use of the bonding agent. The retention rates for the sealants were 77% for Concise with Scotchbond 2, 84% for Concise with no bonding agent; 77% for Prisma Shield with Universal Bond; and 77% for Prisma Shield with no bonding agent.

A study by Arzu Pinar et al (2005) observed that the use of bonding agent as an intermediary layer between enamel and sealant did not affect sealant success during a 24-month period.

Based on the results observed in several studies, the use of bonding agent as an intermediary layer between enamel and sealant did not affect sealant success.

In situations in which control of saliva and isolation is impossible the use of bonding for increasing the quality of fissure sealant therapy is useful.

6.Application of sealent:

In mandibular teeth , apply the sealent distally and allow it to flow mesially with the converse being true for maxillary teeth.

During the applicationof sealant care should be taken to prevent theincorporation of air bubbles.

7.Curing

Done according to the manufacturer’s direction. Once the material is cured fully, it is

examined very carefully with an explorer to make sure that in the sealant application technique:› All the fissures and pits are covered› All the excessive material has been

removed.› Material is firmly adherent to the enamel

surface.

Now a days lasers are used for curing due to the following advantages :

Reduction in setting time. Control of specific radiation energy

wavelengths. Control of area of exposure. Decrease in %age of unpolymerized

resin.

8.Evaluation of occlusion:

Evaluate occlusion of sealed tooth surface with articulating paper to determine if any excessive sealant is present and needs to be removed.

A small discrepancy in occlusion in case of unfilled sealant is easily tolerated as the cement abrades away but in case of filled resin sealant occlusal adjustment is must to avoid discomfort.

9.Recall and re-evaluation:

Sealants must be thoroughly checked at subsequent recall appointments as to ensure that:› The sealant is still firmly adherent to the

tooth and› The sealant material has not been lost.› Thus, if there is any of the sealant

material lost then it must be added during this time.

Effectiveness of sealants:

For the sealants to be very effective, first of all it should be retained which depends upon the following factors:

Technique of sealants application The type of sealant material used and The morphology of the surface of the

tooth to which the sealant is applied to cover the pits and fissures.

Retention and caries prevention:

Horowitz’s landmark Kalispell study (1977). In the 5-year report of this study, the authors reported 42% complete retention at 5 years. Horowitz also noted that teeth with sealant partially missing had a lower incidence of caries (7%) than paired unsealed control teeth that were not sealed (41% caries).

Wendt and Koch (1988) reported on teeth sealed over a 10-year period.

They found that after 8 years, about 80% of the sealed fissures showed total sealant retention and no caries.

Another 16% of the sealed occlusal surfaces showed partial retention and no caries.

After 10 years, only 6% of the sealed occlusal surfaces showed caries or restorations

A 15-year study of the single application of a colored (white) autopolymerizing pit and fissure sealant found 28% complete retention and 35% partial (noncarious) retention on permanent first molars. In a matched-pair analysis, carious or restored surfaces made up 31% of the surfaces in the sealed group and 83% in the unsealed group.(Simonsen,1991)

Cost effectiveness: At the 10-year point of a 15-year study,

it was found that it is 1.6 times as costly to restore the carious lesions in the first permanent molars in an unsealed group of 5- to 10-year-old children living in a fluoridated area than it is to prevent, with a single application of pit and fissure sealant, the greater number of lesions observed if pit and fissure sealant is not utilized(Simonsen RJ,1989)

Estrogenicity issue:

A recent study on the estrogenicity of resin-based dental composites and sealants by Olea and coworkers in Granada,1996, Spain, started a controversy that resulted in considerable confusion and doubt in the minds of many dentists and consumers alike about the safety of pit and fissure sealant.

Concern was raised about the safety of monomers leached out of these materials.

The conversion of monomers during the curing process of a sealant is incomplete, thus residual monomers can leach out of the cured resin.

BPA released orally from a dental sealant may not be absorbed or may be present in non detectable amounts in systemic circulation. The concern about potential estrogenicity of sealant may be unfounded.(Fung et al 2000)

The parental concern about the estrogenicity of sealants is unfounded based on the presently-available evidence. It should also be remembered that none of the dental sealants that carry the ADA Seal release detectable BPA.

Fluoride used with sealants and fluoride-containing sealant:

In an evaluation after 4 years of the combined use of fluoride and dental sealants, the overall proportion of sealants retained on occlusal surfaces of first molars after an average of 2 years is 92%. This study suggests that pit and fissure sealants confer additional caries-preventive benefits beyond those of fluoride therapy alone.(Selwitz et al,1995)

In an analysis of fluoride release from fissure sealants, Garcia-Godoy, Summitt and Donly (1997) found that all the fluoridated sealants tested released measurable fluoride.

However, the greatest amount of fluoride was released in the first 24 hours after mixing, and the fluoride release fell sharply on the second day and decreased slowly for the last days.

Options: filled vs unfilled; colored vs clear; autocure vs light-initiated:Filled vs unfilled:

Penetration, is inversely proportional to the viscosity. Thus, it could be reasoned that an unfilled resin will penetrate deeper into the fissure system, and, therefore, perhaps be better retained.

In a study comparing unfilled and filled sealant in the mouth, an unfilled light-cured resin was significantly better retained than a filled light-cured resin.(Rock et al,1990)

Colored vs clear: In March of 1977, the first colored sealant (3M’s

Concise White Sealant) was introduced . Advantages : Easier to see the sealant during

application, and faster to assess retention with a white sealant.

Documentation of retention is much easier over long time periods with a colored sealant.

Some have argued against use of an opaque color as it precludes continual examination of the sealed fissure.

Autocure vs light-initiated:

  Autopolymerizing resins generally performed

better than the early ultraviolet light-initiated resin sealant—84% complete retention at 2 years compared to 75% in one study. When the visible light-initiated resins were introduced and compared to the autopolymerising sealant, no significant difference was found in retention over 31 months. 

De Craene and coworkers (1989) showed that a visible lightcured sealant (Helioseal) appears to be as good as the self-cured sealants and better than the UV light-cured products.

Glass ionomer materials as sealants:

The logical assumption that a material that releases fluoride, such as a glass ionomer cement, would provide an added benefit to the retentive blocking of the fissure by a resin sealant, has been tested many times with various glass ionomer materials, sometimes in direct comparison with resin materials.

Glass-ionomer (polyalkenoate) cements have documented high levels of fluoride release. However, used as a pit and fissure sealant, the traditional glass-ionomer cements have shown very poor retention rates as well as leakage even when fully retained. (Boksman,1987)

In a study reported by Boksman et al, a comparison of the study’s 6-month complete retention rates of 92% for Concise white light-initiated sealant and 2% for the Fuji III glass ionomer sealant, suggests, according to the authors,that the routine use of the Fuji III glass ionomer as a fissure sealant is unreliable.

Whether the development of the resin-modified glass-ionomer (RMGI) cements can challenge the resin sealants in terms of retention remains to be seen.

But early indications are that the RMGI wears markedly more than the resin sealant.

- Winkler et al, 1996

(Forss et al 1998) conducted a 7-year study looked at retention of a glass-ionomer cement and a resin-based fissure sealant and effect on carious outcome.

The aim of this study was to compare the retention and caries preventive efficacy of glass-ionomer (Fuji III; GIC) and light-cured resin-based (Delton; LCR) fissure sealants.

On the sealed occlusal surfaces, 10% of GIC and 45% of LCR sealants were totally present and 9% of GIC and 20% of LCR sealants partially present.

Twenty three(24%) of the occlusal surfaces sealed with GIC and 16 (17%) of those sealed with LCR were carious or filled.

Kervanto- Seppala S et al (2000) concluded that glass-ionomer sealants, whether resealed or not, cannot be as cost-effective as resin-bonded sealants when the expense of placement in time (and thus cost) is used as the basis of efficacy.

Current status:Fluorescing Pit and Fissure sealent

Use of UV pen light: fluoresces a blue/white color.

Visual verification of sealent margins at time of placement and recall . Eg : Delton Seal-N-Glo

Wetbond pit and fissure sealent

Bonds chemically and micromechanically

to the moist tooth.

First pit and fissure resin sealent that can be applied in moist field.

Pit and fissure sealent with ACP

Light cured sealent that contains “smart material” Amorphous Calcium

Phosphate(ACP).

More resilient and flexible,creating stronger long lasting sealent. Eg:Aegis pit and fisure sealent.

American Academy of Pediatric Dentistry (AAPD) guidelines Recommendations for Pit and fissure sealants (2008):

Sealants should be placed into pits and fissures of teeth based upon the patient’s caries risk, not the patient’s age or time lapsed since tooth eruption.

Sealants should be placed on surfaces judged to be at high risk or surfaces that already exhibit incipient carious lesions to inhibit lesion progression. Follow up care, as with all dental treatment, is recommended.

Sealant placement methods should include careful cleaning of the pits and fissures without removal of any appreciable enamel. Some circumstances may indicate use of a minimal enameloplasty technique.

  A low-viscosity hydrophilic material

bonding layer, as part of or under the actual sealant, is recommended for long-term retention and effectiveness.

Glass ionomer materials could be used as transitional sealants.

PREVENTIVE RESIN RESTORATIONS: A PRR is a conservative treatment that

involves limited excavation to remove the carious tissue , restoration of the excavated area with a composite resin , and application of a sealant over the surface of the restoration and remaining, sound, contiguous pits and fissures. (Ripa et al 1992)

Also called CONSERVATIVE ADHESIVE RESIN RESTORATION.

First reported by Simonsen and Stallard (1978)

Types of PRR:

1.TYPE A : Deep pit and fissure

susceptible to caries. The preparation size

is very small Unfilled resin or

sealant is used to restore the preparation of carious lesions involving round bur of size ½ or less

2.Group B : Minimal exploratory

carious lesion. Since the caries can

be explored the preparation needs to be extended.

Preparation size is by size 2 round bur.

The restoration requires some filler to be added to the unfilled resin.

Types of PRR:

3.TYPE C:Isolated carious

lesion. The presence of

caries is definite and requires considerable preparation.

Larger size bur is used following which a small bevel is placed at cavosurface margin.

Types of PRR:

Advantages:

Conservation of Tooth Structure Aesthetics Flexible preparation design Ease and speed of placement

Procedure: Place a rubber dam to prevent saliva

contamination during tooth preparation

Clean surface of tooth with flour of pumice and a bristle brush

Open into the area of carious lesion with a small round bur (1/2, 2)

Remove only carious lesion

Open adjacent grooves only when necessary to insure they are caries free; use the tip of a diamond or ¼ or ½ round bur, maintain contour of the occlusal surface

Etch the surface of the tooth with a 37% phosphoric acid solution for 15 SECONDS; shorter time than sealant because in dentin , etchant will penetrate farther and it can end with a hollow demineralized spot

Rinse with copious amounts of water to remove etchant

Gently blow air over the surface of the tooth to remove excess water, but leave the surface moist with H2O; don’t want to dehydrate the dentin

Place dentin bonding agent over entire etched surface using a brush› Blow air over area to evaporate solvent› Apply second coat and air dry› Cure for 20 seconds

Place flowable composite in the deepest area of restoration

Disperse to other parts of the preparation using the tip of an explorer

Cure for a minimum of 40 seconds Place sealant material over restored

area and adjacent intact etched pits and fissures.

Check the occlusion with articulating paper and adjust as necessary.

Periodically reevaluate , repair and reapply as necessary.

PRR are an extension of the sealant technique that allow for caries control with minimal loss of tooth structure.

This method is indicated where caries within a fissure has just reached the dentine.

Under ideal circumstances the fissure sealants can successfully prevent progression of caries

(Thylstrup and Fejerskov , 1994)

For early decay, where space allows, glass ionomer veneered with unfilled resin should be used. The main difficulty in determining the optimal form of management for an early decay lesion is the diagnosis of state of the fissure.

Management of doubtful occlusal fissures, with use of air abrasion techniques to open up all suspect fissures and grooves does not fit well with current minimal intervention philosophy, even though it may be easiest solution for the practitioner.

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