12. pit and fissure sealants

Pit and fissure sealant : An

Updating Technique

CHAITANYA.P

III MDS

Dept of Public Health Dentistry

Contents • Introduction

• History

• Definition

• Morphology

• Requirements of materials

• Materials used

• Classification

• Indications & Contraindications

• Age period for sealant placement

• Application

• Advantages & Disadvantages

• Recent advances

• Conclusion

• References 2

Introduction

• Dental caries causes demineralization & destruction of hard

tissues of the tooth, anatomical pits & fissures of the teeth are

susceptible areas for initiation of this dental caries.

• There are several preventive & prophylactic methods advocated

such as regular oral hygiene practices and interventions, dietary

modifications, pit & fissure sealants, preventive resin restoration to

avoid dental caries.

‘Prevention is better than cure’

3

HistoryYears Authors Contribution

1895 Wilson

Placement of zinc phosphate cement in pits

and fissures

1923 Hyatt Prophylactic odontomy

1942 Kline and Knutson Treatment with ammoniacal silver nitrate

1955 Buonocore

Sealing of pits and fissure with bonded resin

material

1971 Pit and fissure sealant recognized by ADA

1972 Nuva seal first commercial sealant

1978 Simonson Preventive resin restoration

1986 Garcia-Godoy Preventive glass ionomer restoration

4

Ref: Norman O.Harris. Primary preventive dentistry, 2014; 8th edition; pearson

publisher, pg:274.

George Babu et al Pit and fissure sealants in pediatric dentistry. SRM Journal

of Research in Dental Sciences,2014; 5(4):253-257.

DefinitionPit:

- A small pinpoint depression located at the junction of developmental

grooves or at terminals of those grooves.

Fissures:

- Deep clefts between the adjoining cusps. They provide areas for

retention of caries producing agents.

According to Simonsen:

Material that is introduced into the pits & fissures of caries susceptible

teeth thus forming micromechanically bonded protective layer cutting access of

caries producing bacteria from their source of nutrients.

According to ADA

An adhesive material that is applied to pits & fissures of teeth in order to

isolate from rest of the oral cavity. 5

Morphology

Two main types of pit & fissures

1) Shallow, wide v – shaped fissures

• Self-cleansing

• Caries resistant

2) Deep, narrow I – shaped fissure

• Constricted

• Resemble a bottle neck:

Extremely narrow slit like opening

Large base towards DEJ

• Caries susceptible

• Number of different branches

6

• According to Nango(1960)

• There are 5 types of fissures based on the alphabetical description of

shape they are

V type

U type

I type

K type

H shaped fissures-seen mostly in premolars.

• Susceptibility of caries is related to form and depth of these pits and fissures.

• The shallow wide V and U shaped fissures tend to be self-cleansing and

somewhat caries resistant.

• Deep narrow I shaped and K shaped fissures are quiet constricted and

resemble a bottle neck.7

Requirements of materials used as sealants

• Reduced water sorption & solubility.

• Increased hardness & abrasion resistance after curing.

• Sufficient strength, surface hardness, dimensional stability.

• Good flow.

• Short setting time & adequate working time.

• Same thermal conductivity as tooth.

• Good bond strength with enamel.

• Chemically inert, anti-cariogenic.

• Low volatility.

• Reduced polymerization shrinkage.8

Materials used

Cyanoacrylates:

• They polymerize to hard & brittle polymers on etched tooth surface

in presence of moisture.

• Mechanical durability is not satisfactory & they are not

biodegradable.

Polyurethanes:

• Not regularly used due to poor mechanical properties, oral

durability & toxicity.

Eg: Epoxylite.

9

Dimethacrylates:

• MMA is highly volatile & lack penetration.

• Enamite, BISGMA are also used.

Glass Ionomer;

• Developed by McLean & Wilson.

• Hydrophilic, good adhesion, biocompatible.

• Used for fissures exceeding 100micrometres

10

ClassificationA. Based on curing method:.

Generation Curing Method

First generation Ultraviolet light 350nm for polymerization, UV

light prevents complete polymerization.

Second generation Self-cured or chemically cured. Most are

unfilled. Filled resins have increased abrasion

resistance.

Third generation Visible light cured of 430-490nm.

Fourth generation Fluoride releasing sealants

Fifth generation Glass ionomer cement as pit and fissure

sealants. Sealants with bonding agents.

Sixth generation Self-etching light cured sealants.

11

B. Based on presence of filler:

• Unfilled-better flow.

• Filled: strong & resistant to wear.

C. Based on appearance or colour:

Transparent Opaque

Clear, pink or Tooth coloured or white

Amber coloured

Colour changes during or

after polymerisation

12

D. Based on fluoride release

• Fluoride releasing sealants

• Non- Fluoride releasing sealant

E. Types of sealants*

1. Glass ionomer cement sealants

2. sealants with bonding agents

3. Self-etching light cured sealants

4. Fluoride releasing sealants

5. Moisture-resistant sealants

6. Colored versus clear sealants

13

* Ref: Norman O.Harris. Primary preventive dentistry, 2014; 8th edition;

pearson publisher, pg:273-283.

Criteria Indications Contraindications

Tooth age Recently erupted Teeth remains caries

free for 4 or >4 years

Tooth type Molar Premolar except when

caries risk is high

Occlusal morphology Deep narrow retentive pit

and fissures

Narrow wide self

cleansing pit and

fissures

Status of proximal

Surface Sound Carious

General caries activity Many occlusal lesions few

proximal lesions

Many proximal lesions

Other preventive

measures

Patient receiving

approach systemic and

topical F therapy and are

still caries active

Indications and contraindications

14

Age period for sealant placement

• The disease susceptibility of the tooth should be considered when

selecting teeth for sealants not the age of the individual.

1. Ages 3 and 4 years are the most important times for sealing the

eligible deciduous teeth.

2. Ages 6-7 years for the first permanent molars.

3. Ages 11-13 years for the second permanent molars and

premolars.

15

Application of pit and fissure sealant

1. Cleaning the pit and fissure surfaces

• Plaque and debris might interfere with the etching process or

sealant penetration. Historically, it has been advocated to clean

the surfaces with bristle brush and pumice. Use of prophylactic

pastes, especially those with fluoride, have been discouraged

because it was thought that the fluoride might make the enamel

surface less reactive to the etchant and thereby reduce the bond

strength. Air abrasion also has been suggested for preparation of

the occlusal surface before sealant application.

16

S. Hatibovic-Kofman et al (1998) Conducted an in-vitro study to

compare the microleakage of unfilled and filled sealants after

conventional(pumice with rubber cup), bur, and air-abrasion tooth

preparation. The study results showed there was no statistically

significant difference in retention of sealant with regard to technique

of tooth preparation before sealant placement.

17

S. Hatibovic-Kofman, GZ Wright, Ian Braverman. Microleakage of sealants

after conventional, bur, and air-abrasion preparation of pits and fissures. Am

Acad pediatr Dent, 1998; 20(3) :173-76.

Julie A. Blackwood et al (2002) conducted an in vitro study to evaluate the

microleakage of pit and fissure sealants after using three different pit and fissure

preparation techniques: (1) traditional pumice prophylaxis and acid etching, (2)

fissure enameloplasty and acid etching and (3) air abrasion and acid etching. The

study results showed that specimens treated with traditional pumice prophylaxis

had higher amount of microleakage compared to other techniques.

18

Ref: Julie A. Blackwood, MS Diane C. Dilley, Michael W. Roberts, Edward J.

Swift. Jr. Evaluation of pumice, fissure enameloplasty and air abrasion on

sealant microleakage. Pediatr Dent, 2002; 24(3).

2. Isolation of the tooth

• 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. The rubber dam, when

properly placed, provides the best, most controllable isolation, and

for an operator working alone, it ensures isolation from start to

finish. Cotton roll isolation offers some advantages over rubber

dam isolation.

19

WF Waggoner and M Siegal. Pit and fissure sealant application: An updating

technique. J Am Dent Assoc, 1996; 127: 351-361.

3. Etching

• Introduction of acid etch technique has made the sealing of occlusal

surfaces more effective. The most critical step in sealant application

technique is acid conditioning or acid etching procedure. Etching

enhances the tooth’s receptivity to bonding with the sealant. During this

critical step, meticulous maintenance of a dry tooth surface is essential

for bonding to be successful. The conventional 60 s etching was first

used by Ripa and Cole. Increased etching time for deciduous teeth is

attributed to various reasons like:

1. Deciduous teeth have less mineral and more organic material in the

enamel.

2. Deciduous teeth have a larger internal pore volume and thus more

exogenous organic material.20

3. Deciduous teeth have more prism less enamel on their surface than

do permanent teeth.

4. The prism rods in deciduous teeth approach the surface at a greater

angle and thus are more difficult to etch.

Three characteristic etching patterns occur following exposure of sound

enamel to phosphoric acid.

Type 1 etching pattern: Prism cores lost but Prism peripheries remain —

honeycomb appearance.

Type 2 etching pattern: Prism peripheries are lost, Prism cores appear to

be relatively intact — cobble stone appearance.

Type 3 etching pattern: Some regions of etched enamel show a

generalized surface roughening and porosity with no exposure of prism

cores or peripheries. 21

• The enamel surface shows a mainly aprismatic or prismless

configuration. Due to phosphoric acid etching and subsequent water-

rinsing of the etched enamel, the prismless enamel surface layer is

removed. Thereby the prismatic structured enamel is exposed providing

sufficient micro-retentive bonding of the fissure sealant.

22

1. Gwinnet AJ. The ultrastructure of the ‘prismless’ enamel of permanent human

teeth. Arch Oral Biol,1967;12: 381—8.

2. Gwinnett AJ. Human prismless enamel and its influence on sealant penetration.

Arch Oral Biol,1973;18:441-444.

3. Kodaka T, Kuroiwa H, Higashi S. Structural and distribution patterns of surface

prismless enamel in human permanent teeth. Caries Research, 1991;25:7—20.

4. Kanemura N, Sano H, Tagami J. Tensile bond strength to and SEM evaluation of

ground and intact enamel surfaces. J Dent, 1999;27:523-30.

5. Hannig M, Bock H, Bott B, Hoth-Hannig W. Inter-crystallite nanoretention of self-

etching adhesives at enamel imaged by transmission electron microscopy. Eur J

Oral Sci, 2002;110:464—70.

Reference

4. Thoroughly rinse and dry the tooth

• Many of the sealant manufacturers recommend rinsing the tooth

for 20-30 s to remove the etchant. An exact rinse time is probably

not as important as ensuring that the rinse is long enough and

thorough enough to remove all of the etchant from the surface.

Drying the tooth with compressed air is likewise done not for a

specific time but rather for a specific result. A tooth that is

completely dried will exhibit a chalky, frosted appearance.

23

5. Application of sealant

• During sealant application, all the susceptible pits and fissures should be

sealed for maximum caries protection. This includes buccal pits of

mandibular molars and lingual grooves of maxillary molars. The sealant

material can be applied to the tooth in a variety of methods. Some

common problems occur during sealant application, Small bubbles may

form in the sealant material. If these are present, they should be teased

out with a brush before polymerization. Unfilled sealants have a low

viscosity that makes them prone to pooling in the distal pit area of

maxillary molars due to patient position and gravity. This can be rectified

by applying the sealant judiciously or by removing excess amounts with a

brush.

24

25

Chosack and Eidelman (1988) found that the longer sealants were

allowed to sit on the etched surface before being polymerized, the more

the sealant penetrated the microporosities, creating longer resin tags,

which are critical for micromechanical retention. Sealants in which

polymerization was not initiated for 20 seconds after application had resin

tags nearly three times longer than those of sealants that were

polymerized after a five- or 10-second delay.

Chosak A, Eidelman E. Effect of time from application until exposure to

light on the tag lengths of a visible light-polymerized sealant. Dent Mater

1988;4:302-6.

6. Evaluation

• The sealant should be visually and tactually inspected for complete

coverage and absence of voids or bubbles. Attempts should be made

to dislodge the sealant with an explorer. If the sealant is dislodged, the

tooth should be carefully inspected to see that no debris has been left

in the fissure, which may have interfered with the bond. Small voids in

the sealant can be repaired simply by adding new material to the void

and polymerizing. Some sealants will be completely or partially lost

and will require reapplication. During routine recall examinations, it is

necessary to re-evaluate the sealed tooth surface both visually and

tactually for loss of material, exposure of voids in the material and

caries development. The need for reapplication of sealants is usually

highest during the first 6 months after placement. 26

*The unfilled sealant sections showed significantly less microleakage than

filled sealants, regardless of the method of tooth preparation.

27

*S. Hatibovic-Kofman, GZ Wright, Ian Braverman. Microleakage of sealants after

conventional, bur, and air-abrasion preparation of pits and fissures. Am Acad

pediatr Dent, 1998; 20(3) :173-76.

** The unfilled sealant showed significantly more retention than filled

sealants.

**V. Rajashekar Reddy et al. Retention of resinbased filled and unfilled pit and

fissure sealants: A comparative clinical study. Contemp Clin Dent. 2015 Mar;

6(Suppl 1): S18–S23.

The sealant effectiveness can be assessed by CCC sealant

evaluation system

CCC sealant evaluation system

• C – Colour: validity of sealant identification and caries

diagnosis.

• C – Coverage: effectiveness of the sealant.

• C – caries: caries status on the surface.

28

29

30

Christopher Derry , A proposed method for assessing the quality of sealants-the CCC sealant evaluation system, J of CDOE, 2001,29; 83-91.

Codes for evaluation of sealant- Ana Luiza Falavinha VieiraI et al 2006

31

32

33

34

Advantages

• It is a non-invasive technique.

• Sealing of pits & fissures prevents tooth decay.

• Fluoride release from fluoridated sealants can confer protection to

adjoining areas.

• Sealants can be used at the community level for prevention of caries.

Disadvantages

• Adverse reaction- allergy to resin (Hallstrom, 1993)

• Caries susceptibility of etched enamel.

• Economic feasibility.

• Inadvertent placement over carious sites.

• Detection of lost sealant. 35

Recent advances in pit and fissure sealants

1. ACP-pit & fissure sealants. (Amorphous calcium phosphate sealant )

Eg: Bosworth Aegis pit & fissure sealants

36

37

Zawaideh FI, Owais AI, Kawaja W. Ability of pit and fissure sealant-containing

amorphous calcium phosphate to inhibit enamel demineralization. Int J Clin Pediatr

Dent 2016;9(1):10-14.

Feda I Zawaideh et al (2016) conducted an in-vitro study on 75 extracted

non-carious third molars sealaed with resin-based sealant (Concise™),

ACP-containing sealant (Aegis®) or fluoride-containing sealant (Conseal-

F™). The results showed that The ACP-containing pit and fissure sealant

has the potential to inhibit enamel demineralization.

2. Moisture tolerant pit & fissure sealants.

Eg: Pulpdent Embarce wet bond

Traditional sealents

• Hydrophobic

• They repel water and cannotbe applied where there isMoisture.

• Bis-GMA is present. (hydrophobic monomer)

• Filled or un-filled sealants

Embrace wet bond

• Hydrophilc.

• Embrace is activated by moisture.

• Embrace WetBond contains nobis-GMA and no bisphenol A.

• It contains fillers (aluminumpowder, carbon fiber, graphite,calcium carbonate, silica, clay)

38

• The Hydrophillic sealant (79.6) showed significantly more retention

than Hydrophobic sealants(73.4).

39

Akurathi Ratnaditya et al. Clinical Evaluation of Retention in Hydrophobic

and Hydrophillic Pit and Fissure Sealants-A Two Year Follow-Up Study .

Journal of Young Pharmacists 2015 ;7( 3);171-179

3. Etch- free light cured sealants.

Eg: Beauti Fill sealant

4. Self-etching Self-adhesive sealant

Eg: Maxcem ellite fill sealant

5. Pen type handling of sealants.

Eg: Ecuseal (Ecu-PEN is autoclavable

up to 130 °C. It will withstand 100 autoclave cycles.)

6. Nano composites as sealants.

Eg: Transeal (Deep penetration and excellent flow rate)

40

Advances in curing of sealants

1. U.V light cure (320-395nm)

2. LED CURING LIGHT (440-490nm)

3. Tungsten halogen curing light (400-500nm)

4. Plasma Arc (400-500nm)

5. LSAER (Light Amplification by Stimulated Emission Radiation)

Eg: Co2 laser improved retention of sealant (10600nm).

Argon laser improved mechanical retention of sealant (488, 514nm).

41

Studies on Sealant

• Huda Nazar et al (2013) conducted a study on Effectiveness of

Fissure Sealant Retention and Caries Prevention with and without

Primer and Bond. Results showed that There was no difference

between teeth sealed with primer and bond and teeth sealed

without primer and bond retained sealant.

42

Huda Nazar et al. Effectiveness of Fissure Sealant Retention and Caries

Prevention with and without Primer and Bond. Med Princ Pract

2013;22:12–17

Priscilla Santana Pinto Goncalves et al(2016) conducted a study Pit

and Fissure Sealants with Different Materials: Resin Based vs Glass

Ionomer Cement. Both the sealants, Fluroshield (Dentsply) and

Clinpro TM Varnish® XT(GIC) were effective in preventing caries

lesion within 6 months, although Fluroshield sealant showed better

clinical retention.

43

Ref: Priscilla Santana Pinto Goncalves et al. Pit and Fissure Sealants

with Different Materials: Resin Based x Glass Ionomer Cement – Results

after Six Months .Brazilian Research in Pediatric Dentistry and Integrated

Clinic 2016, 16(1):15-23

44

Imran Pasha Mohammed et al (2016) conducted a study on

Comparison of effectiveness of traditional acid etching and of the

self-etching agent in sealant retention: A randomized controlled trial.

The study results showed that there was No significant difference was

seen in the retention of fissure sealants placed on occlusal surfaces

following the use of an traditional PAE technique and SE bonding

agent, after 6 months.

Mohammed IP, Jaleel BF, Hiremath SS, Manjunath C, Amarah U, Krishnamoorthy

A. Comparison of effectiveness of traditional acid etching and of the self-etching

agent in sealant retention: A randomized controlled trial. J Indian Assoc Public

Health Dent 2016;14:4-9

Conclusion

Caries is a problem for patients of all ages. Along with proper

diet, fluoride, and biofilm control, pit and fissure sealants

should be considered as part of an overall preventive program

rather than an isolated procedure.

45

References

1. Gwinnet AJ. The ultrastructure of the ‘prismless’ enamel of permanent human teeth. ArchOral Biol,1967;12: 381—8.

2. Gwinnett AJ. Human prismless enamel and its influence on sealant penetration. Arch OralBiol,1973;18:441-444.

3. Simonsen RJ. Chapter 2: Pit and fissure sealants. In: Clinical Applications of the Acid Etch

Technique. 1st ed. Chicago, IL: Quintessence Publishing Co, Inc; 1978:19-42.

4. Chosak A, Eidelman E. Effect of time from application until exposure to light on the tag

lengths of a visible light-polymerized sealant. Dent Mater 1988;4:302-6.

5. Kodaka T, Kuroiwa H, Higashi S. Structural and distribution patterns of surface prismlessenamel in human permanent teeth. Caries Research, 1991;25:7—20.

6. WF Waggoner and M Siegal. Pit and fissure sealant application: An updating technique. J

Am Dent Assoc, 1996; 127: 351-361.

7. S. Hatibovic-Kofman, GZ Wright, Ian Braverman. Microleakage of sealants after

conventional, bur, and air-abrasion preparation of pits and fissures. Am Acad pediatr Dent,

1998; 20(3) :173-76.

46

47

8. Kanemura N, Sano H, Tagami J. Tensile bond strength to and SEM evaluation of

ground and intact enamel surfaces. J Dent, 1999;27:523-30.

9. Hannig M, Bock H, Bott B, Hoth-Hannig W. Inter-crystallite nanoretention of self-

etching adhesives at enamel imaged by transmission electron microscopy. Eur J

Oral Sci, 2002;110:464—70.

10. Julie A. Blackwood, MS Diane C. Dilley, Michael W. Roberts, Edward J. Swift. Jr.

Evaluation of pumice, fissure enameloplasty and air abrasion on sealant

microleakage. Pediatr Dent, 2002; 24(3).

11. Ana Luiza Falavinha VieiraI et al; Evaluation of glass ionomer sealants placed

according to the ART approach in a community with high caries experience: 1-year

follow-up : J. Appl. Oral Sci,2006;14:4

12. Harshpriya et al, Recent trends in preventive dentistry-A review; SRM University

dental journal, 2011;2(3):232-237.

13. Huda Nazar et al. Effectiveness of Fissure Sealant Retention and Caries Prevention

with and without Primer and Bond. Med Princ Pract 2013;22:12–17

48

14. Norman O.Harris. Primary preventive dentistry, 2014; 8th edition; pearson publisher,

pg:273-283.

15. George Babu et al Pit and fissure sealants in pediatric dentistry. SRM Journal of

Research in Dental Sciences,2014; 5(4):253-257.

16. V. Rajashekar Reddy et al. Retention of resinbased filled and unfilled pit and fissure

sealants: A comparative clinical study. Contemp Clin Dent. 2015 Mar; 6(Suppl 1):

S18–S23.

17. Akurathi Ratnaditya et al. Clinical Evaluation of Retention in Hydrophobic and

Hydrophillic Pit and Fissure Sealants-A Two Year Follow-Up Study . Journal of Young

Pharmacists 2015 ;7( 3);171-179

18. Priscilla Santana Pinto Goncalves et al. Pit and Fissure Sealants with Different

Materials: Resin Based x Glass Ionomer Cement – Results after Six Months .Brazilian

Research in Pediatric Dentistry and Integrated Clinic 2016, 16(1):15-23

49

19. Zawaideh FI, Owais AI, Kawaja W. Ability of pit and fissure sealant-containing

amorphous calcium phosphate to inhibit enamel demineralization. Int J Clin Pediatr Dent

2016;9(1):10

20. Mohammed IP, Jaleel BF, Hiremath SS, Manjunath C, Amarah U, Krishnamoorthy A.

Comparison of effectiveness of traditional acid etching and of the self-etching agent in

sealant retention: A randomized controlled trial. J Indian Assoc Public Health Dent

2016;14:4-9.