DOI: 10.1111/ipd.
12281
Evaluation of pit-and-fissure sealants placed with four
different bonding protocols: a randomized clinical trial
MANASI KHARE, BARANYA SHRIKRISHNA SUPRABHA, RAMYA SHENOY & ARATHI RAO
Department of Paedodontics and Preventive Dentistry, Manipal College of Dental Sciences, Manipal University, Mangalore,
India
International Journal of Paediatric Dentistry 2016
Background. Application of adhesive after acid
etching may increase the retention of pit-and-fis-
sure sealants and improve clinical effectiveness.
Aims. To clinically evaluate the retention, mar-
ginal discoloration and caries incidence of pit-
and-fissure sealants applied using four bonding
protocols: conventional acid etching, etch-and-
rinse adhesive, multimode universal adhesive and
self-etch adhesive used after acid etching.
Design. In this split-mouth design study, the four
adhesive protocols were randomly assigned to the
four erupted, non-carious first permanent molars
and involved 52 patients between 6 and 10 years
of age. The sealants were evaluated at 3-, 6- and
Introduction
The application of pit-and-fissure sealant to
newly erupted posterior teeth is the best
method to prevent pit-and-fissure caries1;
however, failures of sealant retention have
been reported over one-year follow-up which
decreases their clinical effectiveness2. The
main reason for the failure of pit-and-fissure
sealants is contamination of etched enamel
by saliva or gingival fluid3. Hence, the appli-
cation of adhesive during sealant placement
which allows optimal infiltration and encap-
sulation of inter- and intraprismatic bound-
aries of etched enamel and the formation of
long adhesive tags has been studied. The
dehydrating activity of solvents in the adhe-
sive such as acetone or ethanol displaces
water from the deep fissure walls and allows
Correspondence to:
Dr B.S. Suprabha, Department of Paedodontics and
Preventive Dentistry, Manipal College of Dental Sciences,
Manipal University, Light House Hill Road, Mangalore –
575 001, Karnataka, India. E-mail:
suprabha.bhat@manipal.edu
© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
12-month intervals. Statistical analysis was car-
ried out using Friedman test and Kruskal–Wallis
test.
Results. At 12 months, the retention rate was
maximum in etch-and-rinse and universal adhe-
sive groups (77.1%) followed by self-etch adhe-
sive (58.3%) and conventional acid etching group
(45.8%). Dental caries was observed only in one
tooth, and marginal discoloration was found to be
the highest in conventional group and least in
etch-and-rinse group.
Conclusions. Use of adhesives during pit-and-fis-
sure sealant application does not significantly
enhance sealant retention nor decrease marginal
discoloration. Etch-and-rinse adhesive is advanta-
geous only at short term.
deeper penetration of adhesive and sealant
resin4. This has been shown to increase bond
strength, reduce microleakage, and improve
short-term clinical success3–5. Both etch-and-
rinse (total etch) type and self-etch type of
bonding agents have been studied. Etch-
and-rinse adhesives have shown higher rate
of complete sealant retention than self-etch
adhesives4,6,7.
Multimode one-bottle universal adhesives
have been developed recently to make the
clinical procedure more user-friendly. These
new adhesives can be used as self-etch or as
etch-and-rinse adhesives. This enables the
clinician to selectively acid etch enamel and
bond to enamel in etch-and-rinse mode and
dentin in self-etch mode with the additional
advantage of chemical bonding to enamel
and dentin8. In vitro studies as well as short-
term clinical studies have reported compara-
ble bond strengths, nano leakage, and clinical
longevity of universal adhesives with etch-
and-rinse adhesives8–10; however, most of
these studies involved dentin as the bonding
substrate. To our knowledge, no studies have
been reported on the use of this bonding
1
2 M. Khare et al.
agent on enamel to aid in the retention of
pit-and-fissure sealants. Hence, this study was
carried out with the aim to evaluate the
effectiveness of pit-and-fissure sealants
applied to teeth using etch-and-rinse, self-
etch, and multimode adhesives during bond-
ing of pit-and-fissure sealants.
The null hypothesis stated was that there is
no difference in sealant retention, fissure car-
ies incidence, and marginal discoloration after
use of self-etch or etch-and-rinse or multi-
mode adhesive in the bonding protocol com-
pared to conventional bonding protocol of
pit-and-fissure sealant.
Methodology
The investigation was designed as a random-
ized double-blinded clinical trial with split-
mouth design, according to the Consolidated
Standards of Reporting Trials (CONSORT)11.
Sample size was calculated as 16 per group,
at 80% power with a possibility of detecting
30% difference in means7, while carrying out
a two-tailed test at 5% significance level.
Sample size was calculated using G*Power
3.012. To compensate for the loss to follow-up
of 20%, final sample size was calculated as 52
in each group. Ethical clearance was obtained
from Institutional Ethics Committee prior to
the study.
A total of 96 patients between 6 and
10 years of age, who visited the paediatric
dental department for routine dental treat-
ment from June to September 2014, were
screened for inclusion and exclusion criteria
during initial examination. Teeth were exam-
ined using mouth mirror and explorer for
non-carious first permanent molars. Simpli-
fied oral hygiene index (OHIS)13, DMFT/deft
index14, and Frankl behaviour rating15 were
recorded. After screening, children with all
four erupted, non-carious first permanent
molars which were completely erupted
through the gingiva, with deep pits and fis-
sures and DMFT/deft 1 or more with satisfac-
tory cooperative behaviour (Frankl score 3 or
4) and oral hygiene (OHI-S ≤ 3) were
selected. Due to these inclusion criteria, vari-
ability within the sample for factors affecting
sealant retention and fissure caries incidence
© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
was minimized. Patients with history of any
medical disease or long-term medication that
might interfere with the study were excluded.
Patients with history of abnormal parafunc-
tional activity, under fluoride application regi-
men, restorations on first permanent molars,
and history of allergies to resins were also
excluded from the study.
Finally, 52 patients were selected for the
study, after obtaining informed consent from
the parents. Thus, a total of 208 first perma-
nent molars, four in each patient, were
included in the study. They were randomly
assigned into four groups using block alloca-
tion (block size 4) by an operator not involved
in other aspects of the study. Randomization
was performed using a random table of num-
bers. Details of the allocated group were
recorded on cards contained in sequentially
numbered, opaque, sealed envelopes.
Sealants were placed according to one of
the following bonding protocols:
Group 1: Conventional acid etching with-
out adhesive (control group)
Group 2: Etch-and-rinse adhesive (Adper
Single Bond 2, 3M ESPE Dental Products,
St Paul, MN, USA)
Group 3: Multimode universal adhesive
(Scotch-bond Universal Adhesive, SU, 3M
ESPE Dental Products) used in etch-and-
rinse mode
Group 4: Self-etch adhesive (G-BOND, GC,
Europe N.V.) used after acid etching
Clinical sealing protocol
Oral prophylaxis was carried out, and teeth
were polished with prophylactic paste and
rubber cups in slow speed hand piece. The
teeth were rinsed thoroughly with water. The
fissures were traced with a fine explorer to
remove any remaining prophylactic paste and
then air-dried. Moisture control was main-
tained by cotton rolls and saliva ejector. All
applications were carried out by a single oper-
ator. The sealants were placed in the grooves
of occlusal surfaces of permanent first molars
(including the buccal groove of lower molars
and palatal groove of upper molars). Sealants
were applied on the permanent molars with
one of the bonding protocols:

Conventional acid etching without adhesive.
Etchant was applied using a micro-applica-
tor brush, left for 15 s, and then washed
with water spray for 10 s. The tooth sur-
face was dried by cotton blotting.
Etch-and-rinse adhesive (Adper Single Bond2).
Etchant was applied using a micro-applica-
tor brush, left for 15 s, and was thereafter
washed with water spray for 10 s. The
tooth surface was dried by cotton blotting.
The bonding agent was applied using the
micro-applicator for 15 s and spread evenly
using air spray for 5 s. The bonding agent
was then light cured for 10 s.
Multimode universal adhesive used in etch-and-
rinse mode (Scotch-bond Universal Adhesive).
Etchant was applied using a micro-applica-
tor and left for 15 s and was thereafter
washed with water spray for 10 s. The
tooth surface was dried by cotton blotting.
The bonding agent was applied using the
micro-applicator and rubbed for 20 s and
then air-dried for 5 s. The bonding agent
was then light cured for 10 s.
Self-etch adhesive used after acid etching
(G-BOND). Etchant was applied using a
micro-applicator and left for 15 s and was
thereafter washed with water spray for
10 s. The tooth surface was dried by cotton
blotting. The bonding agent was applied to
the etched fissures and left undisturbed for
10 s and then gently air-dried for 5 s. The
bonding agent was then light cured for
10 s.
After the respective adhesive application,
the sealant (ClinproTMSealant, St Paul, MN,
USA) was applied to the pits and fissures and
gently teased through the fissure with the tip
of a periodontal probe to prevent voids and
air entrapment. Then, the applied fissure sea-
lants were polymerized using a LED curing
light (Elipar 2500, 3M ESPE, Dental Products)
for 20 s. The cured sealant was checked for
voids using an explorer, which were refilled.
All the sealant applications were cross-
checked using mouth mirror and explorer by
an experienced examiner. The occlusion was
checked with articulation paper. Finishing
and polishing was performed using one-step
composite polishers (Shofu Dental Corpora-
tion, Stone Drive, San Marcos, CA, USA) at
© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Sealants with different bonding protocols 3
low speed. Throughout the study, light out-
put of the curing unit was maintained at
550 mW/cm2 with the help of a radiometer
(Demetron 100, Demetron Research Corp,
Danbury, CT, USA). The light output was
checked after every two patients. The partici-
pants were unaware of the type of bonding
protocol selected for each tooth.
Evaluation of sealant effectiveness
Children were scheduled for evaluation visits
at 3, 6, and 12 months from the date of treat-
ment. All examinations were carried out
using a mouth mirror and explorer, using
visual and tactile method. Sealant retention
was recorded according to the following crite-
ria5: A) complete retention, B) partial loss
(B1, without caries; B2, with caries), C) com-
plete loss (C1, without caries; C2, with car-
ies). Loss of enamel translucency along the
margins, softness at the base of exposed fis-
sures, and defects along the margins with dis-
coloration were denoted as dental caries.
Marginal discoloration to any degree was
recorded as present/absent.
Examination for all teeth was carried out
by a single calibrated examiner who was una-
ware of group allocation. The examiner was
calibrated with an experienced examiner who
was also unaware of group allocation, by
examining the sealants in 10 patients (40
teeth). During calibration, Kappa values for
intra- and interexaminer reproducibility were
0.87 and 0.91, respectively.
Teeth with partial/complete loss of sealants
were repaired by sealant application, and car-
ies was treated with appropriate restorations.
Such teeth were subsequently dropped from
the study.
Statistical analysis
Data were entered, and statistical analysis
was performed using SPSS version 17 (SPSS
Inc., Chicago, IL, USA). Frequency of sealant
retention with and without caries was calcu-
lated in percentages in various groups at
3 months, 6 months, and 12 months. For sta-
tistical analysis, the percentage of teeth in
each group with complete retention of
4 M. Khare et al.
sealant was considered. Friedman test was
used for intragroup comparison, and
Kruskal–Wallis test was used for intergroup
comparison of sealant retention at 3 months,
6 months, and 12 months, whereas the inter-
group comparison of marginal discoloration
was carried out using chi-square test. Pear-
son’s correlation was used to calculate rela-
tion of DMFT score and OHIS score with
sealant retention. For all the tests, level of
significance was set at 5%.
Results
The study sample consisted of 32 males and
20 females. The mean age of the participants
was 8.69  0.98 years. The age distribution
of the sample was as follows: 6 years old
(3.8%), 7 years old (3.8%), 8 years old
(32.7%), 9 years old (38.5%), and 10 years
old (21.2%). Of 52 participants, three partici-
pants did not report for follow-up due to ill-
ness at 6-month follow-up and one
participant did not report at 12-month fol-
low-up due to migration to another city. This
amounts to 7.69% of dropouts which was
well within our estimated dropout percent-
age. The teeth with partial or complete loss
of sealant were eliminated from the study
and were not further followed up. For the
final analysis of the data, the dropouts and
teeth with partial/complete loss of sealant
were eliminated and the rest of the data was
considered as depicted in the flow chart
(Fig. 1).
The sealant retention rate, along with par-
tial and complete loss of sealants (with and
without caries), is depicted in Fig. 2. At the
end of 3 months, the number of teeth with
completely retained sealants was highest in
Group 2 followed by Group 3, Group 4, and
Group 1. After 1 year, complete retention
was highest in Group 2 and 3 followed by
Group 4 and Group 1. Most of the sealant
loss was of partial type with only five teeth
showing complete loss. Etch-and-rinse group
showed the least partial loss followed by uni-
versal and self-etch groups. Caries was
observed only in one tooth which belonged
to Group 3 at 3 months.
© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
A nonparametric Friedman analysis was
carried out for intragroup comparison of sea-
lant retention rate at 3, 6, and 12 months,
which revealed statistical significant differ-
ence over time in etch-and-rinse group
(P = 0.018). There was no statistical differ-
ence in sealant retention rate among other
groups with time (P = 0.368 for Group 1;
P = 0.135 for both Group 3 and Group 4).
Group 2 had the highest complete sealant
retention at 3 months (92.3%) which
decreased to 91.8% at 6 months. But by
12 months, only 77.1% of sealants had been
retained with greatest loss occurring in the 6-
to 12-month period (Fig. 2).
Kruskal–Wallis test was used for intergroup
comparison of sealant retention at 3, 6 and
12 months. At the three-month follow-up, the
difference between the groups was found to be
statistically significant (P = 0.002) but was not
significant at both 6-month and 12-month fol-
low-up (P = 0.119 and 0.952, respectively).
Mann–Whitney U-test after Bonferroni correc-
tion revealed that there was a statistically sig-
nificant difference between Group 1
(conventional acid etch) and Group 2 (etch
and rinse) at 3-month follow-up (Table 1).
The pattern of marginal discoloration, an
early indicator of loss of marginal integrity,
showed similar trends as sealant retention.
Intergroup comparison of marginal discol-
oration using chi-square test revealed statisti-
cally significant difference at 3 months but no
significant difference at 6 months and
12 months (Table 2). Intragroup comparisons
over time at 3-, 6-, and 12-month follow-up
using chi-square test revealed significant dif-
ference in the etch-and-rinse group
(P = 0.02) but not in other groups (P > 0.05).
Pearson’s correlation revealed that there was
no statistically significant relation between
OHIS as well as DMFT/deft scores with sea-
lant retention rate (Table 3) thus confirming
that the level of oral hygiene and dental car-
ies of the participants did not affect the sea-
lant retention rate. Sealant retention was
higher in maxillary molars as compared to
mandibular molars at all follow-up visits, but
the difference was not statistically significant
(v2 = 10.58, P = 0.31).
 Sealants with different bonding protocols 5

Assessment of eligibility and recruitment

(n = 96)

Patients not meeting inclusion criteria

(n = 44)

Recruitment
(n = 52) (Number of teeth = 208)

Block randomization and allocation

(Number of teeth in each patient = 4)

Group 1 Group 2 Group 4 Group 4

n = 52 n = 52 n = 52 n = 52
Conventional Etch and rinse adhesive Universal adhesive Self-etch adhesive

3-month follow-up
Group 1 Group 2 Group3 Group 4
n = 32 n = 48 n = 43 n = 39
Sealant loss = 20 Sealant loss = 4 Sealant loss = 9 Sealant loss = 13

6-month follow-up
Group 1 Group 2 Group 3 Group 4
n = 23 n = 42 n = 39 n = 31
Lost to follow up = 3 Lost to follow up = 3 Lost to follow up = 3 Lost to follow up = 3
Sealant loss = 6 Sealant loss = 3 Sealant loss = 1 Sealant loss = 5

12-month follow-up
Group 1 Group 2 Group 4
Group 3
n = 22 n = 37 n = 28
n = 37
Lost to follow up = 1 Lost to follow up = 1 Lost to follow up = 1
Lost to follow up = 1
Sealant loss = 0 Sealant loss = 3 Sealant loss = 2
Sealant loss = 1

Fig. 1. Flow chart showing trial profile.

universal bonding agent. Randomized con-

Discussion
This study compared the clinical effectiveness
of sealant placed after conventional acid etch-
ing with other bonding protocols using total
etch adhesive, self-etch adhesive, and
trolled trial design used in this study is con-
sidered to be the most reliable evidence for
efficacy of healthcare interventions11. Split-
mouth design chosen in this study removes a
lot of interindividual variability from the

© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
6 M. Khare et al.

3 months 6 months

12 months

Fig. 2. Sealant retention rate with and without caries at 3, 6, and 12 months among the groups.

Table 1. Comparison of sealant retention rate between the period11. Block randomization was used in
groups at 3 months. this study to randomly allocate subjects into
groups with equal sample sizes. This method
Groups Z P Value
ensures a balance in sample size across groups
Group 1–Group 2 3.72 0.000* over time17.
Group 1–Group 3 2.26 0.024 Children aged 6–10 years were selected as
Group 1–Group 4 1.43 0.152
Group 2–Group 3 1.52 0.017
there seems to be benefit in placing sealants
Group 2–Group 4 2.39 0.129 within 4 years after eruption. During this per-
Group 3–Group 4 0.88 0.379 iod, the enamel of the newly erupted tooth is
yet to undergo post-eruptive maturation and
*P < 0.0083 – significant (Bonferroni correction).
hence may be more susceptible to demineral-
ization. The teeth are often in infra-occlusion
estimates of the treatment effect, decreases and achieve complete occlusion only by 2–
sample size which facilitates a relatively 3 years post-eruption, and there is greater
smooth follow-up, increases statistical effi- risk of formation of dental biofilm, thus
ciency as the patient serves as his/her own increasing their susceptibility for dental car-
control; however, loss of one patient during ies18. Children with first molars, fully erupted
follow-up results in loss of data in all the through the gingiva, were included for the
groups, which should be compensated by study to avoid bias due to eruption status as
adequate sample size16. This trial was double- molars which are incompletely erupted
blinded as both participants and examiner through the gingiva have twice the probabil-
were unaware of the type of bonding protocol ity for retreatment owing to inadequate mois-
selected for each tooth during the study ture control during sealant placement5. Poor

© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Sealants with different bonding protocols 7

Table 2. Intergroup comparison of marginal discoloration at 3, 6, and 12 months.

Discolouration Discolouration
Time present absent P
interval Groups N (%) N (%) Total value

3 months Conventional 8 (57.1) 44 (22.7) 52 0.031*

Total etch 1 (7.1) 51 (26.3) 52
Universal 3 (21.4) 49 (25.3) 52
Self-etch 2 (14.3) 50 (25.8) 52
6 months Conventional 6 (12.2) 23 (46.9) 29 0.955
Total etch 7 (14.2) 37 (75.5) 44
Universal 7 (14.2) 36 (73.5) 40
Self-etch 6 (12.2) 28 (57.1) 36
12 months Conventional 4 (8.3) 19 (39.6) 22 0.987
Total etch 6 (12.5) 34 (70.8) 39
Universal 7 (14.6) 32 (66.7) 38
Self-etch 5 (10.4) 24 (50.0) 30

*P < 0.05 – significant.

Table 3. Co-relation between DMFT and OHIS with sealant
retention at 3 months, 6 months, and 12 months.
Time interval Pearson’s
(months) correlation
DMFT 3 0.105
6 0.213
12 0.080
OHIS 3 0.079
6 0.038
12 0.013
behaviour significantly increases risk of sea-
lant failure5,19, and hence in this study, only
patients with Frankl’s positive and definitely
positive behaviour were included.
The results of the present study indicate
that use of bonding agent significantly
increased the success rate of pit-and-fissure
sealants therapy over conventional method
(only acid etching) at 3-month follow-up but
not significantly over a longer time period of
6 months and 12 months.
Use of bonding agent, however, consistently
increased percentage of sealant retention. Fei-
gal et al5 and Sakkas et al4 reported statisti-
cally significant increase in retention of
sealants placed using adhesives at 5-year and
36-month follow-up, respectively; however,
few studies in literature indicate that use of
bonding agent as an intermediate layer may
not be beneficial although a tendency for
improved retention was noted, similar to the
results of our study20–22. The difference in
results of the studies may be attributed to the
variation in the type of bonding agent and
P sealant used, sample size, age group and
value duration of the study.
The reduced acidity of self-etch adhesives
0.460
0.213
leads to a less pronounced etch pattern on
0.675 enamel surfaces as compared to phosphoric
0.254 acid, especially on uncut enamel23. Increased
0.641
0.884
depth of resin penetration can be achieved by
pre-etching the enamel with phosphoric acid
leading to better bond strengths24. Hence, in
this study application of self-etch adhesive
was preceded by a separate phosphoric acid
etching step.
Even though the retention rates of sealant
in self-etch with prior acid etching group
were less than those of etch-and-rinse
adhesive, the values were not statistically
different. Thus, it can be presumed that
etch-and-rinse adhesives performed only
marginally better than self-etch adhesives.
The presence of 4-methacryloxyethyl trimelli-
tate anhydride (4 META) in the self-etch
adhesive ensures chemical bonding with
hydroxyapatitie25. In earlier studies, self-etch
adhesives were used without prior acid etch-
ing resulting in their inferior perfor-
mance4,6,26; however, the advantage of acid
etching is limited by improper penetration of
the resin into the micropores, resulting in a
planar joint like surface, susceptible to crack
propagation, and bond failure26. Gap forma-
tions are seen due to lack of harmony
between the extent of demineralization and

© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
8 M. Khare et al.
the extent of penetration of the adhesive.
These allow for water to leach causing
hydrolysis and deterioration of bonding27.
Bond strengths of different self-etch adhe-
sives vary depending on their pH. Bonding
agent with lower pH results in lowest increase
in bond strength whereas the one with higher
pH results in highest increase in bond
strength25. Not only the extent enamel etch-
ing but also composition and mechanical
properties influence the bond strength to
uncut enamel27. Therefore, the results of this
study are applicable only to the type of self-
etch adhesive used in this study. G-Bond
(GC, Europe), the self-etch adhesive used in
this study, is a HEMA-free acetone-based
adhesive with a pH of 2.4 (mild acidic). As it
is HEMA-free, it is less hydrophilic. This prop-
erty has shown to result in reduced degrada-
tion of mechanical properties during water
storage, thus resulting in no significant reduc-
tion in the bond strength of the adhesive over
time28. The superior performance of etch-
and-rinse adhesive is due to formation of
longer microresin tags within enamel, result-
ing in a scalloped interface which in turn
makes it more resistant to crack propagation
and hence better retention of the sealant26,29;
however, in this study, the retention of the
sealant in etch-and-rinse group was signifi-
cantly higher only at a short-term follow-up
(3 months). Thus, in spite of better bonding
mechanism, there was loss of bonding over
time, due to exposure to masticatory and
thermal stresses. In addition, polymerization
shrinkage tends to pull the adhesive away
from the substrate, causing interfacial stress
thus affecting long-term bonding21.
Multimode adhesive was used in this study
in etch-and-rinse mode, as preliminary etching
of enamel has been found to significantly
increase bond strength to enamel. The
increased demineralization due to acid etching
promotes good micromechanical retention30.
In addition, it bonds chemically to enamel due
to the presence of 10-methacryloyloxydecyl
dihydrogen phosphate (MDP) monomer and
polyalkenoic acid copolymer Vitrebond which
interact with calcium from hydroxyapatite10.
On the other hand, self-etch adhesive used in
this study contains monomer 4-META which
© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
has been found to form a salt with calcium that
dissolves very easily leading to hydrolysis of
the bond. Also 4-META has been found to
have low adsorption on hydroxyapatite25. The
micromechanical bonding of the multimode
adhesive provides strength against mechanical
stress, whereas the chemical interaction
reduces hydrolytic degradation, thus enhanc-
ing retention of the sealants for a longer per-
iod10. This explains the retention of the
sealants with universal adhesive being equal to
that of etch-and-rinse adhesives at the end of
12 months (77.1%), although it was less than
etch-and-rinse adhesive at 3-month and 6-
month follow-up.
In this study, caries was reported only in
one tooth throughout the follow-up period.
Even the teeth with partial and complete loss
of sealants did not present with caries. This is
because many factors other than sealant
retention such as time interval between
actual loss of sealant and follow-up appoint-
ment, oral hygiene, and dietary factors, sali-
vary factors have a potential effect on caries
manifestation31. Moreover, in this study,
when partial/complete loss of sealant was
observed, they were repaired/replaced in the
same appointment and subsequently dropped
from the study. The low incidence of caries in
the sample may also be attributed to this
strategy. In addition, the acid–base resistant
zone formed by all the adhesives as well as
phosphoric acid etching increases the resis-
tance to acid attack by micro-organisms32,33.
Considering that the retention of sealants
was equivocal irrespective of bonding proto-
col, a routine use of intermediate bonding
agent may not be necessary in the absence of
possibility of moisture contamination, taking
into consideration the cost-effectiveness and
increase in complexity of the procedure1. Fur-
ther long-term clinical studies are needed to
confirm the effectiveness of adhesives in sea-
lant bonding protocol.
Conclusion
Under the conditions of this study, the fol-
lowing conclusion can be made:
Use of self-etch or etch-and-rinse or multi-
mode adhesive during pit-and-fissure sealant

application does not significantly enhance
sealant retention nor decrease marginal
discoloration at 12-month follow-up. Etch-
and-rinse adhesive is advantageous only at
short-term 3-month follow-up.
Why this paper is important to paediatric dentists
• The effectiveness of pit-and-fissure sealants placed
using dental adhesives in the bonding protocol was
studied using split-mouth design which minimizes
interindividual variability from treatment effect.
• Effectiveness of four bonding protocols: conventional
acid etching, etch-and-rinse adhesive, multimode uni-
versal adhesive, and self-etch adhesive used after acid
etching were assessed simultaneously.
• As the retention of sealants did not significantly
increase with use of adhesives, it may not be neces-
sary to routinely use dental adhesives for bonding pit-
and-fissure sealants, taking into consideration the
increase in complexity and cost of the procedure.
Conflict of interest
The authors declare no conflict of interest.
Authors’ contributions
Dr. Manasi Khare, Dr. Suprabha B.S, and Dr.
Arathi Rao carried out the research; Dr.Ma-
nasi Khare, Dr. Suprabha B.S, and Dr. Ramya
Shenoy designed the research; Dr. Suprabha
B.S and Dr. Ramya Shenoy analysed the data.
Dr.Manasi Khare and Dr. Suprabha B.S wrote
the manuscript. Dr. Ramya Shenoy and Dr.
Arathi Rao edited the manuscript.
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