Microleakage Evaluation of Two Types of Fissure Sealants

after Enamel Surface Pretreatment

with Erbium Chromium Laser
Aliaa S Rashwan , Magda A El Malt , Nouralhoda F Abdullah
ABSTRACT
Objectives: to assess the microleakage of two different types of fissure sealants after enamel
surface pretreatment with erbium chromium (Er,Cr:YSGG) laser.subjects and methods: Forty
human caries free deciduous teeth were collected. Fissures were cleaned with a dry, pointed
bristle brush and non-fluorinated prophylaxis tooth paste using a low-speed hand piece and
rinsed with water. Fissure surfaces were then dried using oil free compressed air. Samples were
then divided into 4 groups according to the presurface treatment and fissure sealant used, each
group containing 10 teeth.Group I: (sealant only),(Riva conditioner , Riva protect fissure sealant
,SDI Riva coat .Group II: (sealant only),(acied etch ,Ionoseal fissure sealant) .Group III:(pre-
treatment before sealant) by Erbium chromium:(Er,Cr:YSGG) laser and restored as group
I .Group IV : (pre-treatment before sealant) by Erbium chromium:(Er,Cr:YSGG) laser and
restored as group II . Then, teeth was thermos-cycled and then immersed in 2% methylene blue
solution with 500 cycles at 5±2 °C to 55±2 °C for 24 hours, teeth was then sectioned longtidually
bucco-lingually in the middle of the fissure, and examined under the stereomicroscope for dye
penetration. Results: stereomicroscope examination showed that Riva protect group had the
highest microleakage score while the Ionoseal laser group had the lowest microleakage score.
Conclusion: Both Ionoseal fissure sealant and Riva Protect fissure sealant had low microleakage
score significantly although Erbium Chromium Laser group had shows significant difference
between laser treated and untreated groups.

KEYWORD: Permanent Teeth, fissure sealant , Erbium Chromium laser. Paper extracted from
Master thesis titled " Microleakage Evaluation of Two Types of Fissure Sealants after Enamel
Surface Pretreatment with Erbium Chromium Laser ”
Introduction

It is very common that dental caries (tooth decay), is the most prevalent childhood
disease in the world, estimated to cause a loss of 3.5 million disability-adjusted life years.

If left untreated, dental caries can lead to acute abscess Untreated dental caries affects
more than 20% of elementary school-aged children in the USA, and over 50% of children have
ever experienced caries. Among low-income minority children, caries experience can be greater
than 70%, and the prevalence of untreated caries exceeds30%(1).

Pit and fissure caries is the most prevalent caries in primary and permanent dentition
accounting for 80 to 90 percent of the total caries incidence, this is due to the morphology of the
pits and fissures that form an area of food and plaque entrapment which is difficult to clean by
regular tooth brushing, Cariogenic bacteria ferments carbohydrates producing acid that causes
demineralization of tooth surfaces(2).

Sealants have been shown to protect the occlusal surfaces, inhibit bacterial growth, and
provide a smooth surface, thus increasing the probability that the surface will stay clean.
Researches have clearly demonstrated that sealants can be used therapeutically over non-
cavitated carious lesions based on the fact that caries is driven by the biofilm on the surface of
the lesion; if all the dental plaque is removed or the carious lesion is isolated from the biofilm,
then caries will arrest. Therefore, when dealing with occlusal caries, the clinician should follow
the ‘if-in-doubt-seal’ management strategy, as the evidence indicated that this would be effective
and in the best interest of the patient (3).

Over the past 30 years, various materials and techniques have been developed to
improve pit-and-fissure sealant quality and longevity. Traditionally, Riva protect Sealant has
been placed as the most commonly used sealant material. The effect of this material relies on its
micro-retention due to the creation of enamel tags after acid etching. However, Riva protect
Sealant is moisture-sensitive, and under wet conditions, especially in children, GIS might be
more useful due to its hydrophilic characteristics. The caries preventive and arresting effect of
GISs has been credited to its adhesion due to calcium bonds and its ability to leach fluoride into
the oral cavity ,Riva protect is advanced GIS type , Riva Protect Self-cure, encapsulated SDI
Limited, Australia Compartment 1 (powder) Fluoro Aluminosilicate Glass -90 Polyacrylic Acid
– 10 Compartment 2 (liquid) Polyacrylic acid - 25 Tartaric Acid - 10 Balanced ingredient (8).

Advantages of riva protect fissure sealants offer several major advantages over resin
sealants especially in partially erupted teeth. A summary follows , are hydrophilic and they can
chemically bond to tooth structure in a moist environment. This is especially advantageous when
placing sealants in young children where isolation due to location and/or behaviour can be
challenging. Resin sealants only bond mechanically to tooth surfaces. This requires a completely
dry, isolated environment. , release and recharge fluoride. Resin sealants only provide a barrier to
bacterial infiltration while GIs provide a barrier to bacteria, and also release and recharge
fluoride , adhere to enamel and dentin via ionic and polar bonding. This creates intimate contact
and the fluoride is exchanged with the hydroxyl ions in the adjacent enamel hydroxyapatite,
forming fluorapatite which is a stronger, more acid resistant structure (Diagram) , allow for an
easy diffusion of calcium and phosphate ions (in addition to the fluoride ions) from the saliva
into the tooth. This helps to achieve faster, more complete mineralisation and maturation of the
enamel surface. Resin sealants consist of a solid material that seals the tooth and does not allow
for theionic exchange of minerals.,are porous and have large spaces to allow the diffusion of
calcium, phosphate, fluoride, etc and this assists enamel in the maturation process , Newly
erupting enamel is immature as it is composed of carbonate apatite that is easily dissolved , can
be applied as a thin film over the exposed enamel as well as under the operculum of a partially
erupted tooth , has a semipermeable membrane or “skin” that allows calcium and phosphate from
saliva to diffuse through it, into the enamel, and react with the released fluoride to form
mineralised fluorapatite enamel. This mature mineralised enamel is more caries resistant
(Diagram) , penetrate more deeply into enamel fissures and occlusal convolutions than resins (7).

The use of flowable restorative systems has grown in dentistry, mostly due to their
efficient properties such as easy handling, low modulus of elasticity and low viscosity .Ionoseal
is a light-curing glass ionomer composite cement for linings, extended fissure sealing and
treatment of smaller lesions(4)

Over the past two decades, the use of lasers in dentistry has progressed significantly.
While soft tissue lasers were first introduced, they are now commonly used on dental hard tissue
as well, thanks to the advent of new generation lasers. Commonly used laser in dentistry includes
neodymium-yttrium aluminum garnet (Nd:YAG) Glaser, erbium: yttrium aluminum garnet
(Er:YAG), CO2, erbium chromium: yttrium scandium gallium garnet (Er,Cr:YSGG),
holmium:yttrium aluminum garnet Ho:YAG), and diode laser. Treating a pediatric patient with a
laser for oral and dental procedures is advantageous because it reduces the child’s anxiety and
improves parental acceptance(5).

Children become more patient when a clinician uses the laser for a surgical or pulpal
operation, which improves clinical outcomes. In children, laser is used for caries prevention,
early diagnosis, cavity repair, traumatized tooth management, and minor oral surgical
procedures. lasers use in pediatric dentistry appears to be on the verge of becoming the gold
standard. Clinicians should prepare themselves for the new era of laser especially in pediatric
dentistry by knowing laser basics(10)

Lasers are used on hard dental tissues for various procedures, including enamel
conditioning. In previous studies,erbium chromium: yttrium scandium gallium garnet
(Er,Cr:YSGG), (wavelength = 2780μm) laser is suitable for cutting, ablating teeth, removing
caries, and preparing cavities, Er,Cr:YSGG laser energy is absorbed by water in hard tissues,
thereby causing rapid volume expansion with evaporation due to a significant temperature rise in
the interaction zone,Enamel surface conditioning leads to the formation of microcraters, such as
porosities, on the enamel surface, Laser etching provides a theoretical advantage over acid
etching because it increases the resistance of the enamel to acid,The effectiveness of laser
conditioning may vary in terms of different types of fissure sealants(7).

Er,Cr:YSGG Laser may be used for cleaning, and conditioning of pits and fissures before
applying sealant .The use of a laser does not negate the need for acid etching before applying a
sealant. The development of enamel cracks and subsequent micro leakage at the sealant enamel
interface are drawbacks of this process, which can be avoided by curing the sealant material with
an argon laser(6).

Most studies in literature showed the effectiveness of fissure sealant as preventive

agents, however, there is little evidence on their effect when applied after enamel surface pre-
treatment with laser prior to sealant application,. Since sealants with higher adhesion present less
microleakage scores, and thus better clinical performance, therefore, the aim of this in vitro study
will be to evaluate microleakage of two different types of fissure sealants after enamel surface
pretreatment with erbium chromium laser(9).
Subjects and Methods :
Forty human freshly extracted permanent teeth were collected from the of oral
surgery dentistry clinic of the Faculty of Dental Medicine for Girls, Al-Azhar
University. Teeth were carefully examined for any defects such as caries, WSLs,
fractures, cracks or any other defects. Ethical approval for the use of human extracted
teeth was obtained in accordance with the guidelines of the Ethics Committee of the
Faculty of Dental Medicine for Girls, Al-Azhar University .

This study has been approved by Researsh Ethics Committee (REC-PE-23-13) .

Sample size calculation:

The calculation was estimated using ANOVA test or an equivalent non-parametric test
will be used for comparison of between groups. By using G power statistical power Analysis
program (version 3.1.9.4) for sample size determination, A total sample size of 36 (9 in each
group) will be sufficient to detect a large effect size (d)=0.6, with an actual power (1-β error) of
0.8 (80%) and a significance level (α error) 0.05 (5%) for two-sided hypothesis test.

First, teeth were cleaned from soft tissues debris using a dry, pointed bristle brush and non-
fluorinated prophylaxis tooth paste using a low-speed hand piece and rinsed with water. Any
tooth with any of the above mentioned defects was excluded from the study (11).. Teeth were
stored in normal saline solution until the study had begun(12).

Samples were then divided into 4 groups according to the presurface treatment and fissure
sealant used, each group containing 10 teeth.

Group I: (sealant only),(Riva conditioner , Riva protect fissure sealant ,SDI Riva coat .

Group II: (sealant only),(acied etch ,Ionoseal fissure sealant) .

Group III:(pre-treatment before sealant) by Erbium chromium:(Er,Cr:YSGG) laser and restored

as group I .
Group IV : (pre-treatment before sealant) by Erbium chromium:(Er,Cr:YSGG) laser and restored
as group II . Then, teeth was thermos-cycled and then immersed in 2% methylene blue solution
with 500 cycles at 5±2 °C to 55±2 °C for 24 hours, teeth was then sectioned longtidually bucco-
lingually in the middle of the fissure, and examined under the stereomicroscope for dye
penetration.

Figure(1): Ionoseal sealant. Figure(2): Riva protect sealant.

RESULTS:
The microleakage scores per section side for subgroups of both experimental and control
groups are presented in Table (1). Both materials in different conditions showed some level of
microleakage

Table (1): Comparison of microleakage means, SD, and mean ranks between the four groups in
the mesial and distal regions under the different conditions.
Mesial Distal
Groups
Mean Rank Mean ±SD Mean Rank Mean ±SD
Ionoseal laser 9.1b 0.3±0.48b 9b 0.52±0.17b
Riva Protect laser 15.5b 0.8±0.63b 14.5b 1.00±0.67b
Ionoseal 27.15a 1.9±0.74a 27.0a 2.1±0.74a
Riva Protect 30.7a 2.3±0.82a 31.5a 2.5±0.53a
P-value* 0.000S 0.000S 0.000S 0.000S
- Small letters for inter-group comparison (Mann-Whitney test) and the means with different
superscripts are statistically significant different at P ≤ 0.05
-* P-value from Kruskal-Wallis test - S= Statistically significant at P ≤ 0.05

Although the mesial region had the lowest score, mean rank, and mean in all groups,
there was no significant difference between the mesial and distal regions. The laser-treated
groups had the lowest score, mean rank, and mean; there was no statistically significant
difference between the two laser-treated groups.The untreated groups had the highest score,
mean rank, and mean; there was no statistically significant difference between the two
untreated groups.
There was a significant difference between laser treated and untreated groups.The Riva
Protect group had the highest microleakage among all groups, while the Ionoseal laser group
had the lowest microleakage among all groups.

Sealant
Sealant
No Day Day Score 1
penetration penetration
Score 0

Figure (3): (Score 0) nо dye penetration Figure (4): (Score 1) dye penetration

Sealant

Sealant Day penetration

Day penetration Score 3
Score 2

Figure (5): (Score 2) dye penetration Figure (6): (Score 3) dye

penetration
DISCUSSION:
The prevalence of caries in pits and fissures emphasizes the importance of sealants in
preventing caries. The effectiveness of sealants lies in their ability to isolate pits and fissures
from bacteria, nutrients and metabolic acidic product(13)..

The clinical effectiveness of pit and fissure sealants is directly related to their retention.
Sealant retention can be improved by cleaning the occlusal surface before insertion, using
prophylaxis pastes, acid etching, laser etching , air abrasion ,mechanical preparation of fissures.
fissure surface pretreatment with erbium chromium laser which is known as invasive
techniques(14). .

In the present study we evaluate and compare the microleakage of the two pits and
fissure sealants {Self cure conventional glass ionomer (Riva - protect)cement and the resin
reinforced glass ionomer cement (Ionoseal)} under the different surface conditions (Pre-surface
treatment with erbium chromium laser and acid etch , acid etch of fissure sealant according to
manufacturer instruction (control group)) (15). .

In the present study, 2 sections were made through each to evaluate Microleakage of two
different types of fissure sealants after enamel surface pretreatment with erbium chromium
(Er,Cr:YSGG) laser(16). .

In order to enhance the bond strength between the tooth and the fissure sealant, surface
treatment is an essential step. Multiple approaches to surface treatment are available, either total-
etch by the help of phosphoric acid and polyacrylic acid or by laser surface pretreatment(17).

As a result of the study's findings, The laser-treated groups had the lowest score of
microleakage , mean rank, and mean; there was no statistically significant difference between
the two laser-treated groups. The untreated groups had the highest score of microleakage, mean
rank, and mean; there was no statistically significant difference between the two untreated
groups(18).
 There was a significant difference between laser treated and untreated groups. The Riva
Protect group had the highest microleakage among all groups, while the Ionoseal laser group
had the lowest microleakage among all groups(19).

These results came in agreement with those of previous study In which 75 primary
molars which were divided into 3 groups; bur preparation and phosphoric acid etching, laser
pretreatment and phosphoric acid etching and laser pretreatment only. It was concluded that the
lowest microleakge values were assigned to the acid etched enamel specimens treated with
laser(20)..

Also, in other study evaluated the effect of Er,Cr.YSGG laser pretreatment alone or in
combination with conventional acid etching, on the microleakage of resin based fissure sealants
on primary molars and found that laser pre-treatment alone is not able to yield adequate
bonding performance(21)..

In this study, GIC (riva protect) sealant was utilized because of its advantages including
being adhesive and anticariogenic through fluoride charging, added to its low sensitivity to
moisture and low cost compared to resin sealant, being suitable for low income and high caries
incident populations. Several studies had shown no statistically significant difference compared
to resin sealants regarding caries prevention although resin sealants showed higher retention
rates. Preconditioning with acids such as polyacrylic acid was suggested to increase retention
rates of GIC fissure sealants (22)..

These results came in accordance with other studies , it proved that preconditioning
cavities with 10% polyacrylic acid resulted in better chemical and micromechanical retention of
GIC in primary teeth(23).. Also in other stated that GIC formed a morphologic unit with enamel
and resulted in decreased microleakage,as well as in previous study recorded a lowered
microleakage and better contact at enamel/GIC interface after preconditioning step (24,25)..

In thes stady ,VOCO has introduced Ionoseal as a glass ionomer composite cement with
high compressive strength and biocompatibility that can be used quickly (cured by light in a few
seconds) as a suitable material for fissure sealants(26). .
 The result was in conformity with other studies findings which reported less
microleakage amount and higher bond strength of RMGI after selective enamel etching,
respectively(27,28)..
In the previous study, the use of Ionoseal without etching and bonding showed higher
microleakage than surface preparation with acid etch and the application of total-etch adhesive.
However, application of Ionoseal with acid etch and bonding agent presented no significance
difference with other samples in which fissure sealants and flowable composites were applied
with etching and bonding(29)..

CONCLUSION:

Both Ionoseal and Riva Protect had low microleakage , but Ionoseal is preferred.
Erbium Chromium laser can be recommended as an pretreatment tool on tooth surface before
fissure sealant application. Further studies are required to confirm the biological safety of erbium
chromium laser application

RECOMMENDATIONS:

Further studies should be done using in vitro model.

CONFLICT OF INTEREST:

There are no conflicts of interest.

FUNDING :

No funding was received for this study.

ACKNOWLEDGMENT: Iam grateful to Dr. Magda Ahmed El Malt Assistant Professor of

Pedodontics and Oral Health and Dr. Nouralhoda Fathy Abdullah Lecturer of pedodontics
andOral health, Faculty of Dental Medicine, for Girls, Al-Azhar University, Cairo, Egypt.

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