Pit and Fissure Sealants

Cara Miyasaki-Ching, RDHEF, MS

Legal requirements RDA, RDAEF – DDS decision or supervision RDH, DDS/DMD – General supervision Sealant adjustments

Requirements - minimum

16 clock hours total 4 hours of didactic

training 4 hours of laboratory

training 8 hours of clinical

training

Student shall: Have current CPR Take a written exam RDA or RDA eligible

(this includes coronal polish)

Requirements - continued

Patient requirements 18 years of age or older Must be in good health A minimum of four (4) virgin, non-

restored, natural teeth, sufficiently erupted so that a dry field can be maintained.

A minimum of one tooth per quadrant

Certification Requirements

Successful completion of written exam Successful completion of laboratory and

clinical portions of the course

Pit and fissure sealants

A thin plastic coating placed in the pit and fissures of the teeth to act as a physical barrier to decay

Why pit & fissure sealants needed

Bacteria produces acid which causes decay

“demineralization”

Pit and fissure sealants

Over 85% of children (5-17 years old) in US have caries in the pits and fissures

Fluoride is least effective on pit and fissures Only 18% of school-aged children in US have sealants

Effectiveness of sealants

15 year study – 68% of sealed teeth were caries free vs 17% of unsealed control group

Other Preventive Programs

Community water fluoridation

School water fluoridation

Fluoridated toothpaste Fluoride mouthrinse In-office treatment

50-60% (18-40%)

40% 15-30% 31% 26%

Preventive Programs as Related to Sealants Tooth brushing and flossing - mechanical

plaque removal Fluoride – chemical prevention Dental visits – mechanical plaque removal

and chemical prevention

Preventive Programs as Related to Sealants - continued

Diet Minimize exposure to cariogenic foods and

liquids that have little or no nutritional value

Minimize solid and sticky foods Minimize slowly dissolving foods

History of Sealants

Acrylic polymers introduced to dentistry – 1937

Composites - 1960 “Occlusal Sealing” – 1965 Glass ionomers – 1972

Retention of Sealants – 4 year study

Fluoride releasing sealant

91% retention (77% complete & 14% partial)

10% caries rate

Non-fluoride releasing sealant

95% retention (89% complete & 6% partial)

10% caries rate

Retention of Sealants – 2 year study

Fluoride releasing sealant >90% retention No caries

Sealant retention

Sealant Failure

Debris and/or saliva contamination Air inclusion during manipulation – voids Manipulating self-cured sealants late in the

setting reaction

Loss of Sealant

A contaminated site from faulty technique will likely result in complete or partial loss of the sealant within 6-12 months.

Cost Factors

Dental Sealants = $25 - $49 per tooth Amalgam = $75 to $145 per filling Composite = $150 to $200 for a single surface

white composite filling Medical reimbursement Insurance reimbursement

Preventive Resin Restoration

The preparation of fissures by use of air abrasion, bur or laser followed by filling the prep with a flowable composite.

Incipient Caries

Studies have shown that sealants can be placed over incipient caries which arrests the caries process

Most dentists choose to use air abrasion, a bur, or a laser to remove the caries before the sealant is placed

Tooth morphology

Pits and fissures

Tooth morphology

Tooth morphology

Tooth morphology

Why fissures are caries susceptible

Selection of teeth

Considerations Patient age Oral hygiene Caries risk Diet Fluoride history Tooth type Morphology

Selection of teeth - continued

Frequency of pit & fissure caries Lower molars – 50% Upper molars 35-40% Upper and lower second premolars Upper laterals and upper first premolars Upper centrals and lower first premolars

Indications

Deep fissures Incomplete or ill formed pits Newly erupted teeth High caries rate Children Molars

Contraindications

Shallow fissures Well coalesced pits Fluoride rich enamel Low caries rate Occlusal or proximal caries Adults

Partially erupted teeth?

To seal or not to seal?

Operculum (gum flap) – leaks crevicular fluid

Sealant Kits

Cavity Indicators Drying and/or bonding agent (optional) Acid etch Sealant material

Acid Etch

Gel Liquid 3M Innovation:

Adper™ Prompt™ L-Pop™ Self-Etch Adhesive

Acid etch Phosphoric acid 35%-40%-50% Dissolves organic portion of

enamel “micromechanical retention”

Acid etch - continued Creates more

surface area for better adhesion

Also high energy surface

Acid etch - Precautions

Avoid contact with adjacent teeth or soft tissues

Can use mylar strips or matrix bands

Acid etch –Precautions cont.

Active ingredient – phosphoric acid Avoid contact with skin, eyes, and clothing. If skin contact – flush with water If eye contact – flush immediately with water

and seek medical attention If ingestion- do not induce vomiting. Give

large amounts of water or milk. Take an antacid. Call a physician.

Acid etch – storage and handling protocol Protection – protective eyewear, gloves and

clothing Toxicity – mild irritation for skin or ingestion

but damage to eye exposure if chronic exposure.

Storage - Store at room temperature. Handling – Use gloves, protective eyewear and

PPE.

Acid etch - continued

Will an etched tooth be more prone to decay?

Remineralization begins after 24 hours

Drying agent (PrimaDry)

Acid etching and Primadry (alcohol based) allows enamel to be easily “wetted”

PrimaDry – precautions

Active ingredient – ethyl alcohol If skin contact – wash with soap and water If eye contact – flush with lots of water

Ingestion- give large amounts of water or milk.

PrimaDry – storage and handling protocol Protection – protective eyewear, gloves and

clothing Toxicity – mild irritation for skin or ingestion

but severe irritation for eye exposure Storage - Store at room temperature. Keep out

of heat and/or direct sunlight. Handling – Use gloves and protective eyewear.

Sealant composition

A type of specialized plastic (resin) or glass ionomer material

Matrix Filler

Sealant Types

Resin Sealants (Bis-GMA) Bisphenol

A-glycidyl methacrylate resins

Urethane-based resin

Glass Ionomer Sealants Anticariogenic More viscous, less

retention, more brittle and less resistant to occlusal wear

Sealant Types

Filled sealants Unfilled sealants

Accepted Sealant MaterialsADA Council on Scientific Affairs 3M ESPE – Clinpro Sealant Confi-Dental Products Company Dental Technologies Dentsply International - FluroShield Ivoclar Vivadent, Inc. - Helioseal Kuraray America Inc. – Teethmate F-1 PracticeWares Dental Supply Pulpdent Corporation Southern Dental Industries Tru-Tain Prime Dental Ultradent Products, Inc. - Ultraseal Zenith/DMG Dental Manufacturing

Types of curing for sealants

Chemical cured – “autopolymerization” Base and catalyst

Monomer & Initiator + Diluted monomer & 5% Organic Amine Accelerator = Sealant

Visible light cured – “photopolymerization” Pre-mixed

Dimethacrylate + Diluent + Activator + Light = Sealant

Chemical cure sealant materials

Advantages No cure light or risk of eye damage Can apply sealants to several teeth

Disadvantages Variation in setting time (appx 2 min) Voids from mixing material Changes in viscosity over time

Light cured sealant materials

Advantages Short setting time (appx 20 seconds) No mixing required Won’t set-up – longer working time Does not get thick

Disadvantages Potential eye damage due to light cure Additional cost of cure light Cure time increased with number of teeth sealed Difficult to manipulate cure light for posterior teeth

Sealant Shades

Clear Tinted Opaque

Clinpro™ Sealant goes on pink for easy-to-see application, and cures to a natural white.

low viscosity, fluoride-releasing sealant

Sealant Material – precautions

Active ingredient – Bis-GMA Skin contact – wash with soap and water Eye contact – flush with lots of water & call

physician if needed Ingestion- in large amounts induce vomiting

Sealant Material – storage and handling protocol Protection – protective eyewear, gloves and

clothing Toxicity – mild irritation for skin and eye. Low

possiblility of sensitization upon prolonged exposure for the skin.

Storage - Refrigerate when not in use. Handling – Use gloves, protective eyewear and

PPE.

Concepts of bonding

Mechanical bonding – interlocking Chemical bonding – use of adhesive Physical bonding – attraction of atomic

charges

Requirements for Adhesion

Clean surface Good wetting by adhesive Good adaptation to the substrate Good interface Good curing

Strength and Viscosity Characteristics

Viscosity The thicker the sealant the

less likely to penetrate to depth of fissure

Wear of Sealants Considerations for wear –

less filler, more wear and visa versa

Curing units

Conventional cure light with halogen bulb = 20 seconds cure for each surface

Plasma arc or laser = 5-10 seconds

Assemble armamentarium

Assemble sealant kit

Check the operation of the syringe on gauze

Armamentarium

Curing units

CAUTION – Avoid looking directly at the light

Give patient instructions

Verbal instructions I will be placing a

dental sealant on your teeth – it’s like a thin plastic coating on top of the tooth and will help prevent cavities

If you have any problems then raise your left hand

Give patient instructions

Verbal instructions This won’t hurt but

you will need to keep open for a long time and it doesn’t taste very good.

Wear personal protective equipment - operator Gloves Mask Safety glasses/visor Protective clothing Closed toed shoes

Wear personal protective equipment - patient Safety glasses Pt. glasses should be

tinted when using a curing light (operator/assistant should have tinted glasses on shields)

Position patient

Mandibular Maxillary

Check prescription and teeth Occlusal surfaces Buccal and lingual pits

on first molars Lingual pits on upper

anterior teeth

Suspicious lesions?

Explorer – “a stick” Caries indicator dye DIAGNOdent

Prepare the tooth

Bristle brush or rubber cup and plain pumice

Dentist can use bur, air abrasion or laser

Sharp explorer to clean out debris

Rinse

Prepare the Tooth - continued

air abrasion, bur, prophy jet or laser

Position the patient

Check occlusion

Avoid placing acid etch and sealant on marked areas from articulator paper

Isolate tooth/teeth

Treat quadrants separately

To control isolation To prevent

contamination by moisture

Isolate tooth/teeth Rubber dam Cotton rolls Cotton roll holders Dri-angle

Dry tooth

Test air/water syringe before applying blast of air

Apply acid etch

15-20 seconds Use blue micro tip or

brush tip Apply only in pit and

fissures For liquid – dab but do

not rub Re-etch 10 seconds if

saliva contamination

Apply acid etch - continued

3M Innovation: Adper™ Prompt™ L-Pop™ Self-Etch Adhesive

Etch, prime and bond

Apply acid etch Etch pit and fissures Extend 1-2 mm beyond

pit and fissures Avoid cusp tips

Acid etch - continued

Etch longer Deciduous teeth Saliva contamination Air abrasion or prophy

jet used Highly mineralized

teeth

Do not use explorer

Rinse tooth/teeth

Use HVE and a/w syringe

Proper – usually 20 seconds rinse

Avoid saliva contamination

Re-isolate

Dry tooth/teeth

Should appear chalky or frosty white if etched

If not, re-etch for another 10 seconds if not contaminated

with saliva

Apply drying agent (PrimaDry)

Use brush tip Apply and leave for 5

seconds Gently blow air to dry DON’T RINSE

Apply bond agent

A bond agent will improve retention

Apply sealant material

Most posterior tooth first Extend 1-2 mm beyond pit

and fissures Gently work into pits and

fissures Avoid lifting off tooth Don’t overfill “pop” bubbles in sealant

with explorer or brush tip before curing

Light cure for 20 seconds 20 seconds each tooth Don’t touch tip of cure

light to sealant material

Don’t let saliva contaminate the field…..yet

Note: sealant will appear shiny/wet

Light cure for 20 seconds – air inhibition theory Top layer of sealant

will remain uncured sealant will appear

shiny/wet

Check sealed teeth

Use explorer Tooth should be

smooth but not soft Re-apply sealant, if

necessary

(Remove uncured sealant with wet cotton roll)

Remove isolation materials

Moisten Dri-angle Rinse the patient’s

mouth

Check occlusion & contact(s)

Articulating paper Dental floss Ask patient how it

feels Dentist can adjust with

bullet-shaped finishing bur or polishing stone

Give patient instructions

The sealant is hard so you don’t have any restrictions on eating

If it feels “high” after you go home – you can come in to get it adjusted

We will keep checking the sealant at subsequent appointments(if using unfilled corposite sealant the bite will self adjust in 2-3 days)

Documentation

9/1/05 Medical history updated – no changes. Parent consented to sealants on #19 OB and #30 OB. Cotton rolls and dri-angle isolation. Ultraseal etch, primer and light cured sealant used. Patient tolerated procedure well. Informed parent that sealant will be checked at recall appointments.

Infection control

Disinfect unit

Disinfect sealant syringes

Throw away brush tips used in patient’s mouth

Sharp tips need to be placed with sharps container

Common Problems

Re-etch Improperly etched surface – doesn’t appear

frosty and chalky white Dentin etching – need to dissolve smear

layer Contamination of application site – saliva Non-adherence of sealant material

Failure of sealants

Main cause – moisture contamination

Maxillary and mandibular 2nd molars

Early loss means less retention of the resin

Sealing over caries

For incipient caries – risk of progression is very small

Risks associated with sealants

No carcinogens or toxic materials Have xenoestrogens – concentrations too low Potential chemical burns from phosphoric acid Occlusal trauma Danger from cure light

Sealant maintenance

Loss of all or part of the sealant

Staining at edges

Discoloration underneath sealant

Repair of sealant

Reapply if totally lost

Repair partial loss Roughen with

diamond stone Re-etch 20 seconds Reapply sealant

Finished!