Dr.Raed F.

Al-Huwaizi
Lecture 3
Pit and Fissure Sealants:

Introduction:
The anatomical pits and fissures of the teeth are considered to be
susceptible areas for the initiation of dental caries, which is related to the
shape and depth of the pits and fissures. Hence, the occlusal surfaces are
the most affected surfaces with dental caries.
Although worldwide sealants have been proved to be of significant
importance in occlusal caries prevention, sealants are still underutilized.
Approximately 7% of the dentists working in Baghdad City and less than
one percent of the total Iraqi dentists perform fissure sealant application.
The reasons which make a very little number of dentists apply fissure
sealants could be:
1- A dentist’s orientation towards restoration rather than prevention.
2- Inadequate understanding of the technique required.
3- Poor performance by some of the first generation products.
4- A concern for the possibility of sealing in clinically undetectable caries.
5- Most dentists don’t believe in its significance because they are short of
knowledge in this field (especially those that did not study it in their pre-
graduates).
Sealants should be provided as cheap as possible to a larger group of
people to benefit from them.
Early attempts to reduce occlusal caries:
There were many early attempts to reduce occlusal caries. Hyatt in 1923
described the prophylactic odontomy technique, which involves the
mechanical preparation of pits and fissures and filling them with amalgam,
to make less tooth cutting and more conservative than later carious
lesions.
Bodecker in 1929, suggested a technique called fissure eradication, which
involves the widening of the fissures mechanically to make the food
particles less retentive.
Fissure eradication Silver nitrate agents
Many chemical agents were used in attempts to prevent dental caries,
such as ammoniacal silver nitrate by Klein and Knutson in 1942.
In 1955, Buonocore described the acid etch technique by 85% phosphoric
acid for 30 seconds, and in 1965 Bowen developed the bis-GMA resin. This
is the base resin to most of the current commercial sealants. Fissure
sealants of resin base were developed in 1965.
Cariostatic action of sealants:
There will a decrease in the viable bacteria counts in occlusal fissures that
have been sealed up to 2000 folds that of unsealed controls. The intact
sealant will not permit caries to develop or progress, even if sealing deep
carious lesions. The cariostatic properties of sealants are attributed to the
physical obstruction of the pits and fissures. This prevents the penetration
of the fermentable carbohydrates, and so the remaining bacteria can not
produce acid in cariogenic concentration.
Composition of sealants:
There are the chemically curing sealants, which depend on mixing catalyst
and base material and giving time for setting of the material.
The other types of sealants are activated by an external energy source, as
ultra-violet rays, or the use of visible blue light to cure sealants.
The fissure sealant material can be either filled or unfilled. The unfilled or
lightly filled sealants adapt to occlusion because of their lower wear
resistance. Their lower viscosity makes them flow better, thus facilitating
resin infiltration into pits and fissures. In addition, if light curing is used the
light penetration and depth of cure is often better for systems with
minimal filler volume.
Sealant materials may be transparent or opaque. Opaque materials are
available as tooth coloured or white. The transparent sealants are clear,
pink or amber. The clear and tooth- coloured sealants are esthetic but
difficult to be detected at recall examinations.
Selection of teeth indicated for sealing:
Occlusal and proximal caries
Rampant Caries
The teeth should be carefully selected for sealant application. The caries
susceptible surfaces evaluated because caries is unlikely to occur in well
coalesced pits and fissures. The first molars should have the highest
priority, followed by the second molars, while the premolars should have
the lowest priority.
Pit and fissure sealants are contraindicated in cases of rampant caries and
when interproximal lesions are present, therefore, a bitewing radiograph
is essential to indicate no interproximal caries.
A Bitewing X-ray
Fissure sealants are also contra-indicated on occlusal surfaces that are
already carious down to the dentine and distributed in many areas of the
occlusal surface and require restoration.
The sealant application also requires co-operation from the patient to be
able to properly isolate the teeth from salivary contamination.
Manipulation Procedure:
1) Cleaning: For any bonding procedure a clean surface is essential.
Pumice and water can be used for this purpose. A sharp explorer tip then
is run in the pits and fissures to remove entrapped pumice or plaque
remnants. A thorough washing and dryness should then be made.
2) Isolation: the teeth or quadrant of teeth to be sealed should be isolated
using the rubber dam. Most dentists find this method of isolation difficult,
therefore, the use of cotton roll and high volume evacuation with
compressed air may also be used effectively.
3) Etching: The effectiveness of fissure sealants is directly related to
sealant retention. Retention is dependent upon the method of etching and
application. The acid etching technique creates micro porosities in the
enamel surface. This allows the low viscosity resin to penetrate the
roughened surface producing a mechanical lock of resin tags when cured.
The ortho- phosphoric acid solution or gel is used for this purpose in a
concentration of 30- 50% (more commonly in 37%). The etchant agent is
applied by means of either a brush, a small sponge, cotton pellet, or
applicator provided by the manufacturer.
When using very viscous gel etchant air bubbles may be entrapped in the
depth of the fissures, which leads to incomplete and not uniform etching
of the enamel surface.
The etching time for non- fluoridated teeth (topical or systemic) is 60
seconds, whereas for the fluoridated teeth another 30 seconds should be
added. Primary teeth require longer etching time as 90-120 seconds. If any
salivary contamination occurs then the teeth should be re- etched.
4) Washing: A thorough wash is required, for a period of 30-60 seconds.
Then drying the etched enamel with compressed air free of oil
contaminants.
5) Application of sealant:
a) Chemically cured sealant: In addition to the lesser retention rates, there
are other disadvantages such as the incorporation of air bubbles during
the mixing and more oxygen inhibition of the resin during cure.
b) Light cured sealants incorporation of air bubbles is not common,
although there is a lesser chance for it to occur than in chemically cured
sealants, because no mixing is required.
6) Check occlusal interferences: Check them with articulating paper and
adjust the occlusion if necessary. All centric stops should be on enamel. All
excess sealant on the marginal ridge and on tip of cusps should be
removed.
7) Re- evaluation: Sealed teeth should be checked at periodic recall visits
to determine the effectiveness of the sealant. If a sealant is partially or
completely lost then we should repeat it.

Sealed Composite Resin Restoration:

It is an alternative procedure for restoring young permanent teeth
requiring only minimal tooth preparation for caries removal but also
having adjacent susceptible fissures.
The technique involves removing only the carious tooth structure in small
class I cavities. A resin restoration is then placed, and the adjacent pits and
fissures to be sealed at the same time.
After checking for no inter-proximal caries by a bitewing radiograph, the
clinical procedure starts with caries identification by careful visual
examination of a dry occlusal tooth surface. Articulating paper marks on
the tooth would indicate the points of occlusal contact.
The tooth is anesthetized, isolated then removal of the caries is
accomplished. A layer of calcium hydroxide material is placed over the
exposed dentine. Then the enamel is etched, washed and dried
thoroughly. The prepared cavity is filled with composite, and lastly, the
remainder of the pits and fissures are sealed with sealant in the same
previous procedure.