PIT & FISSURE SEALANT

INTRODUCTION
• Tooth surfaces with pits & fissures are vulnerable to caries development.

• Fluorides are highly effective in reducing caries on the smooth surfaces of enamel and
cementum.

• Fluorides are not equally effective in preventing caries in the occlusal pit & fissures,
where 90-95% of caries occurs.

• Dental sealants act to prevent bacteria growth that can lead to dental decay.
 BACKGROUND
• Historically several agents have been utilized to deal with the deep pits & fissures on the
occlusal surfaces of teeth:
• 1895: Wilson reported the placement of dental cements in pits & fissures to prevent
caries
• 1923: Hyatt advocated for the placement of small restorations in deep pits & fissures
before the development of caries.
• 1926: Bodecker suggested that pits & fissures could be broadened with a large round
bur to make the occlusal surface more self cleansing, a procedure called enameloplasty.
• Packing copper amalgam into the fissures
• Do nothing: wait and watch – this option avoids the need to cut the cavity until a definite
carious lesion is identified.
 TYPES OF FISSURE SYSTEMS

• V TYPE: WIDE AT THE TOP AND GRADUALLY NARROWING AT THE

BOTTOM
• U TYPE: ALMOST THE SAME WIDTH FROM TOP TO BOTTOM
• I TYPE: EXTREMELY NARROW SLIT
• IK TYPE: EXTREMELY NARROW SLIT WITH A SPACE AT THE BOTTOM
• INVERTED Y TYPE
 DEFINITION
• A fissure sealant is a material applied to the occlusal surface of the teeth to obliterate
the occlusal pits & fissures & remove the sheltered environment in which caries may
thrive.

• The sealant acts as a physical barrier, preventing oral bacteria and dietary
carbohydrates from creating the acid conditions that result in caries. Placement of a
conventional sealant is a non-invasive technique that maintains tooth integrity while
protecting vulnerable pits and fissures from caries attack.
 TYPES OF PITS & FISSURE SEALANTS
• Fissure sealants are marketed in a variety of formats:
A. Types of fissure sealants :
1. Three kinds of plastics have been used:
I. Polyurethanes
II. Cyanoacyraltes
III. Bhisphenol a glycidyl methacylate (bis-gma)
2. Resin based cements
3. Glass ionomer cements
4. Fluoride containing cements
 TYPES OF PITS & FISSURE SEALANTS

B TYPE OF FISSURE SEALANTS:

1. Filled and unfilled

2. Light cured and chemically (self) cured
3. Clear & tinted
 A TYPE OF FISSURE SEALANTS

POLYURETHANES:
• Among the first to be commercially marketed
• Proved to be soft and totally disintegrated in the mouth after 2-3 months

• They were then used as a vehicle for the application of fluoride to the teeth. This was then
replaced by the use of fluoride varnishes.

CYANOACYRALTES :
• Disintegrated after some time in the mouth
• Discontinued due to low shelf life and high instability

BHISPHENOL A GLYCIDYL METHACYLATE (BIS-GMA):

• Now the sealant of choice
RESIN BASED SEALANT:
• Their caries preventative property is based on establishment of a tight seal, which
prevents leakage of nutrients to the micro flora in deeper parts of the fissure.

• Resin sealants may be pure resins, composites, or compomers, and their polymerization
may be initiated chemically or by light.

• Resin-based sealant utilizes the principles of adhesive dentistry as it is retained by

micromechanical retention.
• For the adhesion of the sealant to the enamel to be successful, the tooth must be clean and remain
dry because the resin is hydrophobic.

• The tooth enamel is etched with 35% to 37% phosphoric acid, which creates surface
irregularities in which the sealant material flows and forms resin tags.

• The resin is polymerized (usually by visible light but there are also autopolymerizing resins) and
forms a thin, plastic coating over the pits and fissures of the occlusal surface.
• This physical barrier is essential in preventing the carious process.
GLASS IONOMER SEALANTS:
• Glass ionomer cement sealants were introduced as an alternative to resin-based
sealants based on their fluoride releasing and recharging ability, their higher moisture
toleration, and their easy application.

• Studies have shown that while glass ionomer sealants are not retained as well, the
caries preventive effect is similar or superior to resin-based sealants.

• Glass ionomer sealants are widely used in countries with limited access to dentistry as
part of the atraumatic restorative treatment (ART) technique.
• Glass ionomer sealants have a different bonding mechanism.

• They adhere to the enamel through both mechanical retention and chemical bonding,
known as chelation. However, the chemical bond alone is weak.

• Glass ionomers are hydrophilic and can withstand some minimal moisture.

• For the glass ionomer sealant, the tooth is cleaned, and a tooth conditioner of
polyacrylic acid is applied. The tooth is rinsed and dried, and the glass ionomer is
placed on the occlusal surface.
FLUORIDE CONTAINING SEALANTS:
• It was based on the concept that the incidence and severity of secondary caries are
reduced or minimized around fluoride releasing materials.

• Based on the knowledge of the benefits of fluoride release from glass ionomer materials,
dental manufacturers have also developed fluoride-releasing resin sealants.

• However, studies have shown that salivary fluoride levels are the same before and after
sealant placement, and there is no long-lasting release of fluoride to plaque and saliva.

• One should not consider fluoride-containing sealants as a fluoride reservoir with long-term
release of fluoride into the immediately adjacent environment
 B TYPE FISSURE SEALANTS

FILLED AND UNFILLED:

• The components of sealants are similar to those of composite resin

restorative materials to include, methacrylate resins, fillers and modifiers.
• Sealants also are available with various filler content.
• For the most part, the filler content dictates the sealant’s physical characteristics
regarding viscosity, flow ability, and resistance to wear.
• Unfilled sealants have some advantages. Unfilled sealants have lower rates of
microleakage and better penetration into the fissures.
FILLED AND UNFILLED:

• Another clear advantage of the unfilled sealant is that occlusal adjustment is not necessary. Due to the lack of
filler, the unfilled sealant will abrade rapidly if left in occlusion

• On the other hand, filled sealants require occlusal adjustment, as individuals are not able to abrade occlusal
interferences caused by filled sealants to a comfortable level.

• Filled materials have greater wear resistance and less porosity.

• Several studies have examined flowable composite as a sealant material. Flowable composite requires the
use of a bonding agent that improves fissure penetration and decreases microleakage.51,52 for clinical
retention, flowable composite is equal to53 and possibly superior to conventional sealant materials.5
LIGHT CURED AND CHEMICALLY (SELF) CURED:
Two methods have been utilized to catalyze polymerization:
1. Light curing (photocure, photoactivation , light activation) by use of visible blue light
2. Self curing (autopolymerization, cold cure, chemical activation) in which a monomer
and a catalyst are mixed together
• The main advantage with light cured sealants is that the operator can initiate
polymerization at any suitable time. It is advisable to store these products away from
bright office lighting, which can sometimes initiate polymerization.
• Requires the purchase of a light source
LIGHT CURED AND CHEMICALLY (SELF) CURED:

• Self curing resins don’t require an expensive light source. However, once mixing has
started and some problem has been encountered the operator will need to continue
mixing or stop and make a new mix.

• Light cured sealants have higher compressive strengths & a smoother surface, which is
probably due to air being introduced into self- cure resins during mixing.
 CLEAR AND TINTED (CLEAR VS COLORED
SEALANTS)
• Available as clear or opaque white.
• The advantages to an opaque sealant are that it is easy to see during application and
easy to monitor its retention at a recall visit.

• Assessment of a clear sealant requires tactile exploration of the sealed surface.

•
• One additional sealant material is available with color-changing properties. Clinpro (3M
ESPE, st. Paul, MN) is a sealant that is pink upon application and turns white when
cured.
 REQUISITES FOR SEALANT RETENTION
• The surface of the tooth must have the following conditions for good sealant retention:
1. Have a maximum surface area
2. Have deep irregular pits & fissures
3. Be clean
4. Be absolutely dry at the time of sealant placement & uncontaminated with saliva.
These are the four commandments of successful sealant placement
INCREASING SURFACE AREA:
• Sealants do not bond directly to teeth - they are made to retain by adhesive forces.

• This can be done by the use of tooth conditioners or etchants which are normally
composed of 30-50% concentration of phosphoric acid.

• The etchant may be in liquid or gel form.

• If any etched area on the tooth surface is not covered with sealant, or if the sealant is not
retained, normal appearance of the enamel will return to the tooth within 1 hr to a few
weeks from remineralisation.
PIT AND FISSURE DEPTH:
Deep irregular pit & fissures offer a much more favorable surface contour for sealant
retention.

The deeper fissures protect the sealant from the shear forces occurring as a result of
masticatory forces.
SURFACE CLEANLINESS:
• Thorough prophylaxis is advocated prior to sealant placement.

• Polishing prophylactic paste should be non fluoridated and an oil free mixture to avoid
contamination of the tooth surface.

• All heavy stains, deposits and debris should be off the occlusal surface before applying
a sealant.
DRYNESS:
• The tooth must be dry at the time of placement of the sealant because present sealants are
hydrophobic

• Presence of saliva on the tooth is even more contradicted than water because its organic
components interpose a barrier between the tooth and the sealant.

• Whenever the teeth are dried with the air-water syringe, the air stream should be checked to
ensure it is not moisture laden.

• A dry field can be maintained by use of rubber dam or cotton rolls combined with the use of high
volume, low volume aspirator.
 PATIENT AND TOOTH SELECTION
• INDICATIONS
1. Presence of deep retentive occlusal pits and fissures of newly erupted molars and premolars which
may cause wedging or catching of an explorer
2. Presence of lingual or palatal pits in relation to upper lateral incisors and molars
3. Stained pits and fissures with minimal appearance of decalcification or opacification (i.E., Incipient
caries with no cavitation;
4. No radiographic or clinical evidence of interproximal caries in need of restoration on teeth to be
sealed
5. Children and young people with medical, physical or intellectual impairment with high caries risk
6. Children and young people with signs of high caries activity and coming from a non fluoridated area
• CONTRAINDICATIONS
1. Well-coalesced, self-cleaning pits and fissures
2. An open occlusal carious lesion with extension into dentin
3. Presence of a large occlusal restoration
4. Radiographic or clinical evidence of interproximal caries in need of restoration
5. No possibility of adequate isolation from salivary contamination either due to eruption
status or patient behavior.
 TECHNIQUE FOR SEALANT APPLICATION

1. CLEANING THE TOOTH:

• For a resin-based sealant to flow into the fissures of the tooth, the fissures must be free
of debris.

• Several methods have been suggested for cleaning the fissures.

• Clean the tooth with pumice slurry and a prophy cup or bristle brush;
 2. ISOLATION
• Resin-based sealants are moisture-sensitive. Saliva contamination significantly lowers
bond strengths because it prevents the formation of resin tags that alter mechanical
retention and thus results in decreased retention.

• Isolation should be achieved by using absolute (rubber dam) or relative (cotton roll)
forms of isolation.

• The most common method of isolation is the cotton roll method, as described by
waggoner and siegal.
 2. ISOLATION

• FOR MAXILLARY ISOLATION:

• A triangular buccal isolation shield, such as a dri-angle, is placed against the buccal
mucosa over the stensen duct with the apex of the triangle directed posteriorly.

• A cotton roll may be placed in the maxillary vestibule to hold the tissue away from the
tooth.

• The mouth mirror is used throughout the entire procedure and should be left in position
throughout the procedure until polymerization of the sealant is achieved. Besides
providing indirect vision, this will also act as a shield for the tongue.
 2. ISOLATION

• FOR MANDIBULAR ISOLATION:

• Cotton rolls are placed on both the buccal and lingual sides of the teeth. A cotton roll
holder may be utilized or the rolls may be held in place with the fingers.

• Excess moisture can be evacuated from the area with the high volume evacuation
suction.

• Utilizing a four-handed delivery method will increase the success of achieving adequate
isolation.
 3. ETCHING:
• Once isolated, the tooth is etched, most commonly with 37% phosphoric acid.
• Using syringe tip, or fiber tip, apply a generous amount of etchant to all enamel
surfaces to be sealed, extending beyond the anticipated margin of the sealant.
• The etchant can be applied liberally and should flow onto all of the susceptible
pits and fissures, including lingual grooves of maxillary molars and buccal pits
of mandibular molars.
• The etchant should extend up the cuspal line angles, 2 to 3 mm beyond the
anticipated margin of the sealant.
• The etchant should remain on the surface for 15 to 20 seconds.
 4. RINSING AND DRYING

• The tooth should be rinsed utilizing the air-water spray and high volume suction.

• The goal of rinsing is to remove all of the etchant from the tooth surface.

• The dry etched surfaces should appear matte, frosty white. If not, repeat steps 1 and 2.
Do not allow the etched surface to be contaminated.

• Do not allow patient to swallow or rinse. If saliva contacts the etched surfaces, re-etch
for 5 seconds and rinse.
 4. RINSING AND DRYING
• Unlike dentin bonding, in which the collagen fibrils should remain moist to prevent
collapsing, the enamel keeps its crystalline structure.

• This means that the enamel should be thoroughly dried or desiccated to maximize the
penetration of the hydrophobic sealant.

• The tooth must remain dry and uncontaminated from this point forward
 5. SEALANT APPLICATION AND
POLYMERIZATION
• The sealant may be applied with a variety of instruments: an explorer tip, a PICH
instrument (a calcium hydroxide, or dycal, placer), or a small brush.

• Many manufacturers offer their own delivery system, which may consist of a preloaded
syringe with a small tip so that the sealant can be applied directly from the syringe to the
tooth.

• The sealant should not be overfilled, to ensure that the sealant material does not extend
past the etched area, to limit the amount of occlusal interference created, and to ensure
optimal depth of cure.
 SEALANT APPLICATION AND
POLYMERIZATION
• If overfilling occurs, the excess material may be removed with a small brush.

• If small bubbles form within the sealant material, these should be teased out before
polymerization.

• Once the sealant has been satisfactorily placed, the curing light tip should be placed as
closely as possible to the surface, and the sealant should be cured for the amount of
time recommended by the manufacturer, which is usually 20 seconds with an light-
emitting diode curing light that has an output of 800 to 1000 mw/cm2.
 EVALUATING THE SEALANT

• Once the sealant has been cured, the operator should visually and tactilely examine the
sealant before removing the isolation materials.

• If the operator discovers bubbles, voids, or areas of deficient material, material can be
directly added at this time because the oxygen inhibited layer has not been disturbed.

• The sealant’s retention should also be evaluated by attempting to dislodge the sealant
with an explorer. If material de-bonds, the fissure should be inspected for remaining
debris. The area should be re-etched, rinsed, dried, and new sealant material applied.
 EVALUATING THE SEALANT
• Depending on the sealant material type, the occlusion may require
adjustment.

• Filled sealants and flowable composite used as sealant require

adjustment, whereas unfilled sealants abrade quickly and are considered
to be “self-adjusting.”

• The occlusion can be adjusted with the use of a round composite

finishing bur in the high-speed handpiece or with a stone or round bur in
the slow speed handpiece.
 PERIODIC EVALUATION

• Sealants should be evaluated at every recall visit.

• Retention of the sealant material is critical to its success. Partial or complete loss of a
sealant results in a surface that is equally at risk for caries as one that had never been
sealed.

• One-time sealant placement does not impart any long-term protection unless the
physical barrier over the fissure, the sealant, remains intact.
 PERIODIC EVALUATION

• Loss of the sealant in any groove or pit renders that pit or fissure susceptible to caries attack.

• Therefore sealants should be maintained and repaired or replaced as needed.

• If a sealant partially remains, attempts can be made to try to dislodge the remaining material with
an explorer. If it remains intact, there is no need to remove the material with a handpiece.

• The tooth may be cleaned with pumice and a rubber cup, and the usual sealant application steps
can be followed, etching both the enamel and remaining sealant and then applying additional
Material.
 REFERENCES
• 1. Dye BA, tan S, smith V, et al. Trends in oral health status: united states, 1988-1994
and 1999-2004. Vital health stat 11. 2007;248:1–92.
• 2. Benjamin RM. Oral health: the silent epidemic. Public health rep. 2010;125(2):158–
159.
• 3. Dye BA, thornton-evans G, li X, et al. Dental caries and sealant prevalence in children
and adolescents in the united states, 2011-2012. NCHS data brief. 2015;191:1–8