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Modern Thoughts on Fissure

Abstract: It has long been known that fissure sealants are an important part of the
prevention and control of dental caries in pits and fissures. However, their usage is still
sporadic and generally not related to evidence-based guidelines. Caries prevalence has
changed since sealants were introduced and this has significant implications for the criteria on
which to select patients who would most benefit from their usage. The clinical technique for
successful fissure sealant application is very moisture and operator sensitive. However,there
is accumulating evidence that use of fissue sealants can be extended, given suitable
investigation, to the early carious lesion as a preventive resin restoration.
Dent Update 2000; 27: 370-374

Clinical Relevance: Prevention of dental caries is still of major importance in Paediatric

Dentistry. However, it is essential that children who are most susceptible to, or most at risk
from, the consequences of dental caries are targeted. Fissure sealants are a highly successful
and very cost effective part of a preventive programme, if used in the right clinical


The concept of sealing fissures and pits
was first suggested in 1967 by Cueto
and Buonocore.1 The development of
the bis glycidyl methacrylate resin and
clinical trials of its use took some time
but fissure sealants have now been
available in clinical practice for well
over 20 years. This certainly does not
mean that they have been widely used
across all developed countries with good
access to clinical services - there is a
rather patchy uptake (see Table 1). In
the USA the 1986 to 1987 National
Health Survey showed a disappointing
use of occlusal sealants in children aged
5 to 17 years of age.2 However, there is

Linda Shaw, PhD, FDS RCS, BDS(Hons), LDS

RCS, Senior Lecturer and Honorary Consultant
in Paediatric Dentistry,The University of
Birmingham Dental Sc hool, St Chads
Queensway, Birmingham B4 6NN.


more recent information to show that

their use is increasing in the USA and in
the UK and Germany.3 Interestingly, it
was shown from the UK Child Dental
Health Survey (1994) that more fissure
sealants were applied in Scotland than in
the rest of the UK, but this may be
related to several factors, including
caries prevalence, which will be
considered later in this article.4 In the
past, because fissure sealants were not
part of the fee per item of Service
under the NHS, there have been
suggestions that fissure sealants were
probably applied more to the teeth of
children whose parents could afford to
pay privately rather than to children who
actually needed them. The capitation
scheme that was introduced was an
attempt to put a much greater emphasis
on preventive care for children. In the
more recent assessment of capitation in
the General Dental Service, an increase
in the numbers of fissure sealants
applied in regularly attending children

and adolescents was found.3


The efficacy of fissure sealants in
preventing dental caries in both pits and
fissures has been shown in many clinical
trials. There have been comprehensive
literature reviews considering use,
retention and effectiveness in preventing
caries and the clinical guidelines of the
American Academy of Paediatric
Dentistry (1998) specifically state that
sealants play a significant role in the
prevention and control of dental caries.
They are intended to protect caries
susceptible tooth surfaces which are
benefited least by fluoride. However,
their clinical effectiveness is only part of
the equation. Most published studies do
not consider cost-effectiveness, cost
benefit or cost utility of the procedures.
It is almost impossible to quantify in
realistic human or child terms (not that

Usage generally low and unevenly

distributed across developed countries.
Recent evidence for increased use in
UK, USA and Germany.
Affected by dental school training
those attending preventively orientated
schools used more fissure sealants.
In USA and Australia there was a
greater use by practitioners whose
knowledge base was greater.
Greater use by dentists involved in
continuing education.
Low usage by practitioners concerned
about sealing in caries.
Low usage by those concerned about
cost-effectiveness and decreasing caries
Table 1: Sealant Usage.
Dental Update October 2000


Figure 1. Section through a molar fissure that is

well sealed and intact. Although there is some
demineralization at the base of the fissure with
the probability of bacteria left in situ, it is
impossible for any cariogenic substrate to
penetrate and therefore the bacteria will
become non-viable.

children arent human!) the savings in

discomfort from having a sealant placed
rather than a restoration. Having
undertaken random surveys for years on
people who have had both procedures
carried out, there has not been one who
preferred having a filling! Fissure
sealants are also an extremely good way
of introducing a child to operative care
and acclimatizing them to dentistry in
general. The realistic financial value of
this is impossible to quantify. A critical
review of methods for the economic
evaluation of fissure sealants was
published by Lewis and Morgan (1994)5
and this revealed a number of problems
within studies. Economic evaluation of a
procedure may improve the quality and
consistency of decision making in
dentistry and will remain an important
consideration, however, from an ethical
standpoint, the protection of oral health
and freedom from disease cannot be
assessed purely in economic terms.
Restorations themselves are also not a
permanent solution when preventive
regimens have failed. They have to be
replaced with alarming and monotonous
regularity and cost benefit analyses are
fraught with difficulty. The relative cost
of different restorations in the UK was
assessed by Mjor, Burke and Wilson
(1997)6 who reported a median longevity
of 7 years for amalgam, 3.75 years for
composite and 4.75 years for glass
ionomer restorations. The problem with
the restoration/re-restoration sequence is
not just cost but destruction of tooth
Dental Update October 2000

tissue, sometimes referred to as the

countdown of a tooth, and the molar
life cycle.
After an exhaustive search through the
published literature, including a metaanalysis of factors influencing the
effectiveness of sealants,7 the conclusions
are irrefutable fissure sealants are
effective in preventing dental caries.
They are also cost- effective, not just
when applied under the controlled
circumstances of clinical trials, but also
in dental practices,8 and when applied by
dental auxiliaries.9


Since the early days of the use of fissure
sealants there have been significant
reductions in the prevalence of dental
caries. The introduction and widespread
use of fluoridated toothpaste is probably
the most important reason for this but
other factors such as diet, oral hygiene
practices, some extension of community
water fluoridation, and possible changes
in oral microflora, are also contributory.
It has therefore been suggested that
fissure sealants are no longer required
and are no longer cost-effective. This is
factually incorrect but highlights that we
must change our clinical practices with
changing circumstances.
Caries is not distributed equally
across countries or communities. It is
quite apparent that the majority of caries
is confined to a minority of children.
The greatest decline in caries in recent
years has been in previously low risk
groups.10 Children who have had caries
in the primary dentition have a greater
chance of having caries in permanent
teeth. There are clearly established
correlations between the lower socioeconomic groups and increased caries
prevalence. If the majority of published
studies are examined across the world,
then it can be demonstrated that
approximately 25% of the worlds
children have at least 65% of the total
caries. However, another change in the
pattern of caries is also becoming
apparent, this is the belief that caries is
predominantly confined to children and


is not a problem past adolescence.

Recent longitudinal studies suggest that
there is a sustained susceptibility to
caries and that the development of caries
is merely being delayed, not eradicated.11
There are, therefore, indications for the
use of fissure sealants in adults.


The answer to this question plainly
should be everyone given the
correct targeted selection criteria. The
hidden question refers to costeffectiveness and value for money
which takes into consideration the
personnel and facilities used for
undertaking these procedures. Dentists
are expensive! Fissure sealant
techniques can legally be delegated to
dental hygienists and dental therapists.
These two groups within the
Professionals Complementary to
Dentistry (PCDs) have been shown to
provide high quality care at
significantly less cost than the general
dental practitioner. The dentist needs to
undertake diagnosis and treatment
planning but, with well organized and
judicious use of operating anxiliaries,
the costs of fissure sealing can then be


There is no doubt that dentists have
been concerned about the possibility of
sealing in caries and the undetected
progression of this beneath fissure
sealant. Numerous studies have
documented the arrest of caries beneath
intact sealants. Composite restorations
which deliberately seal over caries
have been shown to arrest the progress
of carious lesions over a period of nine
years.12 Viable bacterial counts in the
lesions have reduced dramatically after
successful sealant applications and
there has been little, if any, caries
progression, as long as the sealant
remains intact. These results led the
National Institute of Dental Research to
advocate sealant use on incipient




Figure 2. A relatively recently erupted lower

right second permanent molar in a thirteen-yearold who has already lost the first molar due to
caries. This fissure appears to be suspicious.

lesions.13 Figure 1 illustrates the point

that, if fissure sealant is intact, there
can be no penetration of substrate to any
bacteria left at the base of the fissure.
However, all clinicians who regularly
undertake treatment for young people
will have come across surprising,
apparently very small cavities in enamel,
which have devastating dentine
involvement, sometimes known as the
fluoride bomb. If such lesions are
sealed, it is more unlikely that the
sealant will remain intact because of the
undermined enamel. Figures 2, 3 and 4
show a seemingly small superficial
lesion which, on investigation, proved to
be a large cavity. If a fissure is stained
and suspect on visual examination, a
bite-wing radiograph may help as far as
the diagnosis of dentinal caries is
concerned. Other diagnostic methods
involving electronic systems such as
electrical resistance measurement or
laser and air abrasion techniques may be
helpful in the future. If these diagnostic
methods are inconclusive then a
Biopsy technique should be tried.14
Using a very small round or very fine,
short, tapered bur the suspicious fissure
or pit is investigated. If this proves to be
caries extending well into the dentine
then obviously a conventional
restoration is required as in Figures 2
and 3. If there is only a small amount of
enamel undermined then a composite,
glass ionomer (polyalkenoate) or
compomer can be used with a covering
sealant to involve all the remaining
fissure system. This has become known
as the Preventive Resin Restoration,
(PRR) (see Table 2).

This question partly, but not entirely,

comes back to a consideration of costeffectiveness, cost benefit and cost
utility. There is no doubt that not all
fissures are going to become carious.
Not all children are caries susceptible
and not all children are at high risk of
the consequences of dental disease or its
treatment. Not all children are cooperative for dental care. The decision
as to whether to undertake fissure
sealants should be a clinical one after
taking into account the child (or adult)
and all their associated risk factors. The
British Society of Paediatric Dentistry
has prepared a policy document on the
use of fissure sealants.15 The following
patient groups are recommended for
selection for sealants:
Children and young people with
Individuals who are disabled in such
a way that their general health would be
jeopardized by either the development
of oral disease or the need for treatment;
Children and young people with
caries in their primary teeth should have
all susceptible sites on permanent teeth
Significant medical conditions which
put children at risk from the
consequences of dental disease include
cardiac problems, immunosuppression,

Investigate Clinically
- Visual examination
- Electrical Resistance Measurements
- Lasers
- Air abrasion techniques
- Fibre-Optic Transillumination
Investigate Radiographically
- Occlusal caries may show as a
shadow at the amelo-dentinal junction;
- Caries may show beneath a fissure
Investigate using a Biopsy technique
- Use a very small round or short
tapered bur;
- If caries extends into dentine
conventional restoration is required;
- If minimal amounts of enamel ar e
undermined then a composite , glass
ionomer or compomer is inser ted with
covering sealant over all fissures.
(Preventive Resin Restoration)

Table 2. The Suspicious Fissure and Pit.

Figure 3. A 'Biopsy' undertaken of the

suspicious lesion shown in Figure 1 has
revealed extensive occlusal caries.

bleeding disorders, blood dyscrasias and

metabolic and endocrine problems.
These do not necessarily mean that the
person is susceptible to caries but they
will be much more at risk if caries does
develop. Children with physical
disabilities and limitations of manual
dexterity may also be regarded as a
priority group. However, some children
with learning disabilities may not have
the co-operation necessary for fissure
sealants to be applied with the degree of
moisture control that is vital to success.


Although primary molar teeth have not
normally been regarded as teeth to be
sealed, there are some situations when
this may be required. For example, if
there is no permanent successor and the
primary molar is to be kept in the mouth
for some time, or if children fall into the
priority groups as above. These children
should also have the susceptible sites of
all permanent teeth sealed; these include
the pits and fissures of permanent
molars and palatal pits on incisor teeth.
The upper lateral incisor is a common
site for a palatal invagination which may
become carious and jeopardize pulpal
If one of the permanent molars has
become carious then there is very good
Dental Update October 2000


Figure 4. The caries found in Figure 2 was so

extensive that it was restored with a
conventional amalgam material.

scientific evidence for sealing the other

three as quickly as possible.16 If first
permanent molars have become carious,
the second molars should be sealed
when they erupt.
The advice always given was to seal
teeth as soon as they were erupted
sufficiently to obtain adequate moisture
control, particularly teeth with deep
fissures. There is now increasing
evidence that teeth may become carious
many years after eruption and certainly
fissure sealants are more likely to fail
when placed on newly erupted teeth.
Potential risk factors need to be reassessed on an individual patient basis
at frequent intervals. If sealants become
defective they need to be replenished in
order to maintain their marginal

There are many new advances in dental
materials and there is now increasing
choice in light cured and chemically
cured sealants those activated by
ultraviolet light have long ago been left
behind. Chemically cured fissure sealant
retention is at least 60% after 5 years.
The light cured systems have been less
evaluated in longitudinal studies as they
are a more recent introduction.
However, the studies that are available
suggest that light cured resins are
perhaps retained even better than
chemically cured ones.
Although alternative materials such as
glass ionomers (polyalkenoate cements)
and compomers have been suggested as
alternatives to the Bis-GMA resins, the
Dental Update October 2000

scientific evidence on retention and

caries prevention has shown these not to
be as efficacious. There have been more
recent studies suggesting that the glass
ionomer cements can be regarded as a
fluoride depot rather than just a
physical barrier.17 This material may be
used where patient co-operation is
doubtful, perhaps as an interim measure
until compliance improves.
Some manufacturers have deliberately
incorporated fluoride into sealants in an
attempt to improve caries prevention.
There are two common methods of
fluoride incorporation, an anion
exchange system (organic fluoride
compound chemically bound to the
resin) and the addition of a fluoride salt
to unpolymerized resin. At present, all
the commercial products that are
available fall into the latter group. In
vitro studies have shown that the surface
lesion depths of artificially induced
caries lesions were significantly reduced
when a fluoride releasing sealant was
compared with a conventional sealant.18
Conseal F (Southern Dental Industries
Ltd, Bayswater, Victoria 3153 Australia)
is a sealant which gives an intensive
initial fluoride boost in conjunction with
long-term fluoride therapy. It is light
cured and of low viscosity which helps
fissure penetration. However, it would
be fair to say that the incorporation of
fluoride into a resin may compromise
the integrity of a sealant and long-term
in vivo studies are still required to
determine if the fluoride addition
improves caries inhibition.
A recent review by Morphis et al.19
has considered the clinical and in vitro
evidence for the use of fluoride pit and
fissure sealants.
There has also been a recent
suggestion that use of dentine bonding
agents may substantially enhance the
sealant retention rate. The primer
monomers associated with the fourth
and fifth generation dentine bonding
agents are more effective in penetrating
the surfaces of etched enamel than a
conventional fissure sealant, probably
owing to their extremely high diffusion
co-efficient.20 If two coats of the primer
are applied followed by a fissure
sealant, a higher retention rate has been


shown. This could be particularly

important on primary teeth where
etching and retention are more
problematic. More research on this
aspect is certainly required as this could
be a considerable step forward.

Fissure sealants are only a part of the
programme of prevention, but an
important part of the armamentarium
against dental caries. They must be
combined with other preventive
methods and are particularly useful in
combination with optimal water
fluoridation and with topical fluoride
use. However, prevention is not an easy
option. It demands a change in
philosophy from the old drill and fill
to highly developed communication
skills and a thorough understanding of
dental disease and how to avoid it.


Cueto EI, Buonocore MG. Sealing of pits and

fissures with an adhesive resin. J Am Dent Assoc
1967; 75: 121-128.
2. Epidemiology and Oral Disease Pr evention
Program. National Institute of Dental Research.
The national survey of dental caries in United States
school children 198687. National Institute of
Health 1989. Publication Nos. 89-1147.
3. Holloway PJ, Blinkhorn AS, Hassall DC, Mellor AC,
Worthington HV. The assessment of capitation in
the General Dental Ser vice Contract. 1. The level
of caries and its treatment in regularly attending
children and adolescents. Br Dent J 1997; 182:
4. OBrien M. Childrens Dental Health in the United
Kingdom 1993. London: Office of Population,
Census and Surveys, 1994.
5. Lewis JM, Morgan MV. A critical review of
methods for the economic evaluation of fissure
sealants. Community Dent Health 1994; 11: 7982.
6. Mjor IA, Burke FJT, Wilson NHF. The relative cost
of different restorations in the UK. Br Dent J 1997;
182: 286289.
7. Llodra JC, Bravo M, Delgado-Rodriguez M, Baca P,
Galvez R. Factors influencing the effectiveness of
sealants a meta analysis. Community Dent Oral
Epidemiol 1993; 21: 261-268.
8. Ismail AJ, Gagnon P. A longitudinal evaluation of
fissure sealants applied in dental practice.
J Dent Res 1995; 74: 1583-1590.
9. Riordan PJ. Can organised dental care for children
be both good and cheap? Community Dent Oral
Epidemiol 1997; 25: 119125.
10. Manton DJ, Messer LB. Pit and fissure sealants:
Another major cornerstone in preventive dentistry.
Aust Dent J 1995; 40: 2229.




11. Ripa LW, Leske GS, Varma AO. Longitudinal

study of the caries susceptibility of occlusal and
proximal surfaces of first permanent molars.
J Public Health Dent 1988; 48: 813.
12. Mertz-Fairhurst EJ, Adair SM, Sams DR, et al.
Cariostatic and ultraconser vative sealed
restorations: Nine year results among children
and adults. ASDC J Dent Child 1995; 97107.
13. National Institutes of Health. Consensus
development conference statement on dental
sealants in the prevention of tooth decay.
J Am Dent Assoc 1984; 108: 233236.
14. Smallridge J. Management of the stained fissur e

A Clinical Guide to Complete Denture
Prosthetics. By J.F. McCord and A.A.
Grant. BDJ Books, London, 2000 (76pp.,
29.95). ISBN 0-904588-64-5.
This is a new addition to the clinical guide
series published by the British Dental
Journal. The majority of the material has
already formed a series of published
articles in the Journal and, as is customary
following publication, a stand-alone book
has been released.
On first impressions the book is
attractive. It is in A4 format and the
material is well illustrated. The introductory
chapter sets the scene and this is important
for, as the authors stress in the second
paragraph, This book is not intended to
replace standard textbooks of
prosthodontics, but rather to serve as a
chairside guide/aide memoir of clinical
procedures for the general dental
practitioner with an interest in complete
denture therapy. This statement should be
borne in mind as the reader progresses
through the book.
To start, this is a useful book for the
interested postgraduate practitioner as it
acts as complementary material to those
who are reading around the subject. It does
demand a good understanding of the basics
of complete denture prosthetics as some of
the concepts are at an advanced level.
Examples include the use of a papillameter
and the re-introduction of the Gothic Arch
tracing technique. The authors do cover a
variety of techniques as they advance
through the progression of complete
denture construction. The chapters follow a
traditional approach with each covering in
turn: the history and examination,
impressions, registration, trial dentures and

in the first permanent molar National Clinical

Guidelines and Policy Documents. Dent Pract
Bd 1999; 33-36.
15. British Society of Paediatric Dentistr y. Fissure
sealants in Paediatric Dentistr y Policy
Document. January 2000.
16. Broadeur JM, Payette M, Galarneam C.
Treatment cost savings with universal coverage
of dental pit and fissure sealants in Quebec.
J Can Dent Assoc 1997; 63: 625632.
17. Williams B, Laxton L, Holt RD, Winter GB.
Fissure sealants: a 4 year clinical trial
comparing an experimental glass pol yalkenoate

cement with a bis glycidyl methacrylate resin

used as fissure sealants. Br Dent J 1996; 180:
18. Hicks MJ, Flaitz CM. Caries like lesion
formation around fluoride realising sealant and
glass ionomer. Am J Dent 1992; 5: 329334.
19. Morphis TL, Toumba KJ, Lygidakis NA. Fluoride
pit and fissure sealants: a review. Int J Paed Dent
2000; 10: 90-98.
20. Hotta K, Mogi M, Miura F, Nakabayashi N. Effect
of 4-MET on bond strength and penetration of
monomers into enamel. Dent Mat 1992; 8:

delivery of complete dentures. The

information is sound and practical and will
help the more able dentist interested in
Prosthetics to explore alternative methods
of treating the edentulous patient. The last
chapter covers specific clinical problem
areas and is a real gem! There are practical
tips on conventional immediate complete
dentures, copy (template) dentures, relines
and rebases, overdentures and implantretained complete dentures. This last
chapter could form the basis for a new
series of articles.
Although overall the book is well written,
there is some unevenness in the style that
detracts overall. For example, Chapter 3 is
strong on text with some pictures but little
in the way of aide memoir tables. This is
different from Chapter 10 which is
predominantly a set of tables with little text
and pictures.
In spite of these niggles, it must be
stressed that the authors ought to be
congratulated for breathing new life into a
difficult subject area that has been covered
before. I would recommend practitioners to
buy the book in order to allow a fresh
approach and different perspective.
Professor A.D. Walmsley
Birmingham Dental School

research of Dr Jens O Andreasen.

Treatment Planning for Traumatized Teeth
is true to its title. The book consists of 11
short chapters. These cover anatomical
considerations, classification of injuries,
examination, crown fractures, root
fractures, subluxation, extrusion, intrusion,
luxation and avulsion. Trauma to the
supporting structures and to the primary
dentition are also included. True to the
Quintessence Publishing Co. format, the
book is very well produced with their use
of high quality, coloured photographs,
exceptionally good black and white prints
of radiographs and colourful diagrammatic
The layout of the book with its mix of
pictures and text is very pleasing to the eye
and easy to read. However, some small
quirks in translation and editing into the
English version have meant that, in a
couple of places, it is difficult to understand
and this could confuse someone who is not
familiar with the basic management of
traumatized teeth. The tooth notation
system used is one with which I am not
familiar. Nevertheless, the cases used by the
author to illustrate the injuries and their
management show clinical expertise of the
highest order, despite the fact that surgical
intervention has been favoured in some
instances when a more conservative
approach may have been indicated. One
interesting observation is that the
traumatized teeth of Japanese children
appear to require bleaching more often that
those of British children.
This is a well produced book giving
concise information and recommendations
on the management of traumatized teeth. It
will be a useful addition to the books on my
Iain Mackie
Central Manchester Healthcare NHS Trust

Treatment Planning for Traumatized
Teeth. By Mitsuhiro Tsukiboshi.
Quintessence Publishing Co. Ltd., 2000
(120pp., 48). ISBN 0-86715-374-1.
This book was a delight to review. I read it
from cover to cover in a weekend. It
reminded me of reading a good novel; I did
not want to put it down. The author is
Japanese and the contents of the book are
heavily influenced by the publications and

Dental Update October 2000