Pit and fissure sealants

CONTENTS
 Introduction
 Definitions
 Morphology Of Fissures
 History
 Indications
 Contraindications
 Advantages
 Ideal requirements of sealant
 Preventive effects of the sealants
 Who should get sealants?
 Which teeth should be sealed?
 How should teeth be assessed for sealant?
 When should sealants be applied?
 Classification Of Sealants
 Materials used and recent advances
 Steps In Placement Of Sealant
 Cost effectiveness
 Estrogenecity issue
 Review of literature
 Conclusion
 References
 Dental caries - A progressive irreversible microbial disease affecting
the hard parts of tooth exposed to the oral environment, resulting in
demineralization of the inorganic constituents and dissolution of the
organic constituent, thereby leading to a cavity formation
DEFINITIONS
 

 Pit: It is defined as a small pinpoint depression located at the junction of development

grooves or at terminals of those grooves. The central pit describes a landmark in the

central fosse of the molars where development grooves join.

 Fissure: It is defined as deep clefts between adjoining cusps. They provide areas for

retention of caries producing agents. These defects occur on occlusal surfaces of the

molars and premolars, with tortuous configurations that are difficult to assess from

the surfaces. These areas are impossible to keep clean and highly susceptible to

advancement of carious lesions.

PIT AND FISSURE CARIES

 Pit & fissure caries develops in the occlusal surface of molars &
premolars, in the buccal & lingual surface of the molars and in the
lingual surface of the maxillary incisors

 They accounts for abt 60% of total caries experience in children's &
adolescents

 Lesion starts on the lateral surface of fissure

 Triangular shaped with base directed towards dentine

 Occlusal fissure can be extremely diverse in shape describe
as:

-Broad or narrow funnels

-Constricted hourglasses

-Multiple invagination inverted Y shaped division

-Irregularly shaped.
 Carious lesion starts at both sides

of the wall & shows visual changes

such as chalkiness, yellow, brown

or black discoloration

 Enamel rods flares laterally in the bottom of the pits & fissure. When
caries occurs it follows the direction of the enamel rods & forms
triangular or cone shaped lesion with its apex at the outer surface &
base towards the DEJ
 Produce greater cavitation than proximal smooth surface caries.
 Carious dissolution starts in the center of one end of
crystal & develops anisotropically along c- axis

After formation of the central hole, the dissolution extends

as lateral localized destruction towards the external surface.
 Nagona 1960 classified fissure morphology into 5 types

V type 34%
I k type 26%
I type 19%
U type 14%
Other type 7%
DCNA 2002
Modern approach to the treatment of tooth decay

Based on “Medical Model” of caries management

“Extension for Prevention” to “Prevention of

Extension”

“Drilling and Filling” to “Filling without Drilling”

have become the two major goals of minimal

intervention dentistry.
Principles of minimal intervention Dentistry

Control the disease through

reduction of cariogenic flora

Re mineralize early lesions

Repair, rather than replace,

defective restorations.

Perform minimal intervention

surgical procedures as
required
 Pit and
fissure
sealants
DEFINITION
 A chemically active liquid material that is introduced into occlusal
pits and fissures of caries – susceptible teeth, that after application,
either cures chemically or is cured with visible light source, thus
forming a micromechanically bonded protective layer that prevents
the invasion caries producing bacteria, and simultaneously cuts off
the access of surviving caries – producing bacteria from their source
of nutrients.

Australian dental association 2011:56; 45-58

 A resin material that is introduced into the occlusal pit and fissures
of caries-susceptible teeth for the purpose of acting as a physical
protective barrier against caries-producing bacteria entering the
tooth- soben peter

 occlusal surfaces in young patients have a high caries susceptibility.

 The incidence of caries is relatively low on smooth, self cleansing
surfaces (i.e., buccal, lingual, mesial, distal) where fluorides are
highly effective in reducing decay
HISTORY
Hyatt – 1922 – prophylactic restorations

Bodecker – 1929 – widening of fissures – Fissure Eradication

Gore – 1939 – used polymer as sealant

Used soln of cellulose nitrate in organic solvents to fill the surface
enamel made porous by the action of acids in the saliva

Buonocore – 1955 – Attachment of acrylic resin to tooth surface was

greatly increased after treatment of enamel with conc phosphoric acid
Bowen – 1962 – used BIS GMA
too viscous & requires dilution with other monomers

Roydhouse – 1968 – used BIS GMA monomer using MMA

as a diluent together with peroxide amine polymerization
system
30% reduction in caries over a period of 3 years

Buonocore – 1970 – utilized same system but employed an

ultraviolet sensitive polymerization system
 Indications-

1. A deep or irregular fissure, fossa, or pit is present, especially if it catches the tip of
the explorer (for example, occlusal pits and fissures, buccal pits of mandibular
molar, lingual pits of maxillary incisors).

2. The fossa selected for sealant placement is well isolated from another fossa with a
restoration present.

3. An intact occlusal surface is present where the contra lateral tooth surface is
carious or restored.

4. If there is no radiographic evidence.

Robinson, Debi., MS. Ehrlich and Torres Essentials of Dental Assisting, 3rd ed.
Philadelphia: W.B. Saunders Company, 2001.
 Contraindications-

1. Patient behavior does not permit use of adequate dry field (isolation)
techniques throughout the procedure.

2. There is an open occlusal carious lesion.

3. Caries, particularly proximal lesions, exist on other surfaces of the

same tooth (radiographs must be current).

4. A large occlusal restoration is already present.

5. If pits and fissures are well coalesced and self-cleansing

 Other Considerations:

 Where cost-benefit is critical and priorities must be established

 ages 3-4 are most important times for sealing primary molars, ages 6-8
for first permanent molars

 Ages 11-13 for second permanent molars. These ages correspond with
normal eruption patterns.

 Sealant should be considered for adults if there is evidence of impending

caries susceptibility, for example following excessive intake of sugar, or
drug-or radiation induced xerostomia (abnormal dryness of the mouth).

 The disease susceptibility of the tooth should be considered, not the age
of the individual.
ADVANTAGES
 Properly applied, sealants are very effective in preventing decay in pits and
fissures.
 Even early decay appears to stop when covered with a sealant, because decay-
causing bacteria are unable to survive when cut off from their food supply.
 The application of a sealant is quick, easy and painless. No drilling or freezing are
required.
 A properly placed sealant will last for about as long as a typical amalgam filling.
Even if a sealant is damaged or lost, it is easily repaired or replaced.
 Sealants are safe for use on everyone’s teeth, from young children to adults.
REQUISITES OF AN EFFECTIVE SEALANT:

 A viscosity allowing penetration into deep and narrow fissures even in

the maxillary teeth.
 Adequate working time.
 Rapid cure.
 Good and prolonged adhesion to the enamel.
 Low sorption and solubility.
 Resistance to wear.
 Minimum irritation to tissues.
 Cariostatic action.
PREVENTIVE EFFECTS OF THE
SEALANTS
Sealants have three important preventive effects:
 Sealants mechanically fill pits and fissures with acid – resistant
resins.
 Because the pits and fissures are filled, sealants deny cariogenic
microorganisms their preferred habitat.
 Sealants render the pit and fissures easier to clean by tooth brushing
and mastication.
WHO SHOULD GET SEALANTS?
WHICH TEETH SHOULD BE SEALED?

 In children and adolescents, priority should be given to sealing first and

second permanent molar teeth
 primary molar teeth is not recommended - but may be considered for
selected high caries risk children
HOW SHOULD TEETH BE ASSESSED FOR
SEALANT?

 Visual dental examination is the starting point for dental assessment and
treatment planning.

 The assessment of occlusal surfaces is particularly challenging, due to

their complex morphology.

 The basic prerequisites for visual caries detection are clean, dry teeth
and good illumination

 dental radiography, light-based technologies e.g. fibre-optic

transillumination, quantitative laser fluorescence (DIAGNOdent) or
lightinduced fluorescence (QLF)
WHEN SHOULD SEALANTS BE
APPLIED?

 sealants should be applied as soon as the tooth is sufficiently

erupted to be isolated
CLASSIFICATION OF SEALANTS
BASED ON GENERATION –
First generation sealants:

-polymerized by UV-light at a wavelength 356 μm.

-Excessive absorption

-incomplete polymerization of sealant at its depth.

-variable output intensity

-output not uniform

Second generation Sealants/Self curing resins

- Based on catalyst – accelerator system

- Most are unfilled.

- May be transparent, tinted or opaque by inclusion of

white pigment or a tint for better visualization.

eg . Concise [3M] white sealant system, Delton.

 Third generation sealants:

-Light cured by visible light at wavelength 430 nm-490nm.

- May be classified as filled or unfilled, and with or with out tint.

-Most of the unfilled resins are colored white.

-Filled resins are either clear or yellowish

Perform Better Than Self Cure Resins

 Fourth generation sealants:

-Are those containing fluorides.

FLUORIDE INCORPORATION IN FILLERS

 Fluoride is added to unpolymerized resin in form of soluble salt

 Releases fluoride for extended period: 24 hrs. to 30 days

 An organic fluoride compound is chemically bound to resin

 An ion from saliva diffused into resin , exchanged with fluoride ion
– which then is diffused out and is released
BASED ON FILLER CONTENT:

 Unfilled [ free of fillers ]

-flow is better

-retention is more

-abrade rapidly

eg . Concise White

 Filled

- need for occlusal adjustments

- more resistant to wear

eg. Prisma shield

BASED ON CURING:

1. AUTOPOLYMERIZING .

- Better retention 88%

- Sets by exothermic reaction

2. LIGHT CURE

- 75% retentive
BASED ON TRANSLUCENCY
1. CLEAR

-Esthetic, but difficult to detect at recall examination.

-Better flow than tinted or opaque

2. OPAQUE

Adv:

- It is easier to apply

- It is easier to check for complete coverage & polymerization

- Easier & much faster to check for retention at recall visit

- Excess sealant spillage onto tissue or bubble in the sealant can be easily seen & corrected
during application
LISTING OF RESIN SEALANTS
 Clinpro Sealant 3M-ESPE  Seal-Rite Pulpdent

 Conseal F SDI Delton Dentsply  Sealant Bisco

 Delton FS Dentsply  Virtuoso Sealant Den-Mat

 Delton Plus Denstply

 Embrace WetBond Pulpdent

 Enamel Loc Premier

 Fissurit Voco

 FluroShield Dentsply

 Guardian Seal Kerr

 HelioSeal Ivoclar Vivadent

 HelioSeal Clear Chroma Ivoclar Vivadent

 HelioSeal F Ivoclar Vivadent

 Advantages Dis advantages
Self Cure simple to use Once mixing has started, the
operator must continue mixing and
immediately
equipment place the sealant, or stop
and make a new mix if a
problem should occur.

Less expensive--does not The catalyst and base must be mixed

require additional mixing and prior to placement , increasing the
immediately chance of incorporating air bubbles
Equipment into final product.

Light cure Operator has control over Requires extra piece of

the initiation of polymerization equipment that can break down.

Supplied as single liquid High cost of curing light

so no mixing is required. and shorter shelf life of
material
RESIN SEALANTS V/S GI SEALANTS

 Durability & Seal

 Tech. Sensitive
Moisture-Friendly
 Static
Dynamic
 No Ca
Fl, available
& Phosphate
Fl, Ca or
arePhosphate
available
 MATERIALS USED
Composite resin

Glass inomer cement

Compomer
RECENT ADVANCES
Pit and fissure sealant with ACP

 Recently, a RBS containing amorphous calcium phosphate has been

introduced.

 Resin-based composites with amorphous calcium phosphate- to

release calcium and phosphate ions, which remineralized a caries-

like lesion in enamel.'''

 The abilities of these different types of sealants to prevent the

development of caries as an added benefit to the obliterating

property of conventional sealants – Aegis -R

PEDIATRIC DENTISTRY V 33 / NO 7 NOV / DEC 2011

 Self Etch Sealant and Hydrophilic Sealant

ONE-STEP®
(Bisco
 Fluorescing pit and fissure sealants –
 Through the use of UV pen light this sealant fluoresces a blue/ white
color
 The fluorescent glow provides clinicians with a visual verification of
the sealant margins at the time of placement – delton seal-N-Glo.

Wet bond pit and fissure sealant:

 It bonds chemically and micromechanically to the moist tooth,
integrating with the tooth structure to create a strong,margin free bond
that virtually eliminates micro leakage
 It forms a unique resin acid integrating network – improves penetration
of resin – provides superior sealing of the margins- Embrace Wet bond
PLACEMENT PROCEDURE
 ARMAMENTARIUM

1.Air/water syringe
11.Dappen dish with pumice
2. Mouth mirror 12. Acid etch syringe

3. Explorer 13. Sealant applicator with dispensing tip

4. Evacuator tip 14. Bur

15. Prophy brush

5. 2 x 2 gauze squares

6. Cotton rolls

7. Cotton pellets

8. Forceps/cotton pliers

9. Articulating paper

10. Curing light

STEP 1. SELECT APPROPRIATE TEETH

Teeth should be evaluated in terms of:

1. overall caries susceptibility

2. existing restorations and carious lesions

3. occlusal anatomy
STEP 2. PUMICE OCCLUSAL SURFACE AND
RINSE

 Flour of pumice applied with a rotary brush - for cleansing the tooth
surface of debris.
 Many operators advocate the use of hydrogen peroxide for the
Prophy Jet® (an air-driven polishing system) rather than pumice for
optimal plaque removal
STEP 3. REMOVE PUMICE FROM GROOVES
WITH EXPLORER

 Pumice particles may become wedged in deep pits and fissures.

 Check all pits with explorer to be sure any remaining pumice or
plaque has been removed..
STEP 4. ISOLATE

 Rubber dam isolation is ideal but cotton roll isolation is most commonly used.

 Garmer clamps are very effective in maintaining a dry field.

 With these clamps, a long cotton roll may be placed in the mandibular

vestibule and wrapped in a horseshoe-shape fashion to extend to the maxillary

vestibule thus isolating the maxillary and mandibular teeth of the same side at

the same time

 This way the mandibular teeth are sealed first- - then the maxillary teeth, so

that an entire side of the mouth is sealed all at once.

 A garmer clamp also may be used with two short cotton rolls for isolation of

the mandibular teeth

STEP 5. DRY AND ETCH

 Thoroughly dry the tooth (30 seconds) to prevent dilution of the acid etch
solution
 Apply etchant solution with the acid-etch brush
 Place the etchant 2/3 up the cuspal slopes using a gentle dabbing motion.
 Usual etching time for permanent teeth is 60 seconds
 Deciduous teeth should be etched for 1 ½-2 minutes
 fluoresced teeth (teeth that have been stained or pitted due to excessive
fluoride during formation) should be etched for 15 seconds longer than
regular time.
STEP 6. RINSE 20-30 SECONDS

 Rinsing for the full 20-30 seconds is crucial in removing surface by-
products of etching which interfere with sealant retention.
STEP 7. RE-ISOLATE

 This is the most vulnerable time for saliva contamination of the

etched enamel to occur.
 If it does occur, re-etch the tooth surface for 30 seconds
STEP 8. DRY 20 SECONDS – CHECK ETCHED
SURFACE

 The tooth must be completely dry before placing the sealant or it

will not be retained
 The etched surface should be a dull, chalky white. If the tooth does
not appear frosty white, etch again for 15-30 seconds.
STEP 9. APPLY SEALANT IN 30 SECONDS

 Self-cured or Autopolymerized sealants:

 Have the sealant ready to dispense quickly.
 Add 1 drop of catalyst to 1 drop of base. Mix for 5 seconds.
 A brush or a small disposable tube (cannula) – can be used
 Immerse the tip of the tube in the sealant mix and release
the lever.
 The applicator will draw up an amount suitable for an
occlusal surface
 Apply sealant in a relatively thick layer extending approximately 2/3 up the cuspal slope.

 Touch the applicator to a mesial inclined plane, depress lever gradually, and allow it to flow

into the fissures toward the distal

 Run the tip of an explorer through the grooves to remove any air bubbles and to assure full

coverage.

 If it appears there is too much material, it may be removed by lightly touching with a cotton

tip applicator or cotton pellet.

 If the sealant is chemically polymerized, it will set up in 1-3 minutes. Check the leftover

mixture in the plastic mixing well to see if it is hardened.

 If so, the tooth may now be checked for polymerization as well.

 There will always be a greasy film, called the air-inhibited layer, left on the top surface of

the sealant.

 This should be wiped off with a cotton pellet or rinsed off with water.
 Light-cured or Photopolymerized Sealants:

 Dispense 1-2 drops of sealant material into the mixing well (2

drops is sufficient quantity for one quadrant)

 After the material has been placed, initiate polymerization with

the light source.

 Expose all coated surfaces for 20 seconds, keeping the light

guide about 1-2 millimeters from the surface

 After the sealant has set, rinse or wipe the occlusal surface
STEP 10. CHECK APPLICATION WITH
EXPLORER

 All margins should be checked to make sure that they are

flush with the tooth and that application was successful
 Move the tip of the explorer back and forth across the
margins and try to “pry” the sealant away from the
enamel.

 If there are any voids or air bubbles, or if complete

coverage is not attained, additional sealant can be added
without re-etching if a dry field has been maintained.
RECALL STATUS OF TOOTH TREATMENT

Recall Status of Tooth Treatment

All pits and fissures covered No treatment required

Sealant missing from some of all of Reseal the exposed pits and fissures (i.e.,
the pits and fissures; exposed surface sealant replaced)
sound

Sealant missing from some of all of Restore the carious pits and fissures
the pits and fissures; caries present
Dental Sealants and Fissurotomy.flv
SEALANT FAILURE

 Contamination
 Inadequate surface preparation
 Incomplete or slow mixing
 Too slow application of the material
 Air entrapment due to whipping or vigorous mixing
 Over-extension of the material beyond the conditioned tooth surface
 Outdated materials
COST EFFECTIVENESS
 It was found that it is 1.6 times as costly to restore the carious
lesions in the first permanent molars in an unsealed group of 5- to
10-year-old.

Simenson Pediatric Dentistry – 24:5, 2002

Burt noted that cost-effectiveness of sealants would be enhanced by:

(1) using trained auxiliaries to apply sealant to the fullest extent allowed
by law

(2) applying the most recently developed sealants in which retention

rates appear to be most favorable,

(3) their application in areas where proximal caries is low.

ESTROGENICITY ISSUE
 Dental resin composite materials and pit and fissure sealants have a
similar basic composition, which can include bis-glycidyl dimethacrylate
(Bis-GMA), urethane dimethacrylate (UDMA) and triethylene-glycol
dimethacrylate (TEGDMA).
 The conversion of monomers during the curing process of a sealant is
incomplete, thus residual monomers- bis phenol A can leach out of the
cured resin.
 leaching of these unbound molecules into different solvents like saliva
can pose a health hazard.
AN EVALUATION OF NANOCOMPOSITES AS PIT
AND
FISSURE SEALANTS IN CHILD PATIENTS
SINGH S, PANDEY RK

 Evaluated the microleakage and penetration depth of three different types of dental

materials,

 (A) Conventional pit and fissure sealant

 (B) Flowable composite

 (C) Flowable nanocomposite.

According to the results,

 the nanocomposite was found to be an excellent dental material for penetration in

deep pits and fissures, though it exhibits mild microleakage.

 Hence, it can be recommended for use in pediatric dental patients, as a pit and fissure

sealing agent
JOURNAL OF INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE DENTISTRY 2011
THE SUCCESS RATES OF A GLASS IONOMER CEMENT
AND A RESIN-BASED FISSURE SEALANT PLACED BY
FIFTH-YEAR UNDERGRADUATE DENTAL STUDENTS

 Evaluated retention and caries prevention of a glass-ionomer cement

(GIC) and a resin-based fissure sealant

CONCLUSION
 The retention of GIC sealants was markedly inferior to the retention
of resin-based sealants
 however, GIC when used as a pit and fissure sealant was slightly
more effective in preventing occlusal caries.
European Archives of Paediatric Dentistry 13 (Issue 2). 2012
PREVENTIVE RESIN RESTORATION

 The preventive resin restoration is natural extension of the use of

occlusal sealants.
 It integrates the preventive approach of the sealant thearapy for
caries susceptible pit and fissures with therapeutic restoration of
incipient caries with composite restoration that occur on same
occlusal surface

 The preventive resin restoration is the conservative answer to the

conventional “extension for prevention” philosophy of class l
amalgam cavity preparation.
SIMENSEN CLASSIFICATION

Type A

 Suspicious pits & fissures where carious removal is limited to enamel

 Local anesthesia is not required

 A slow speed ¼ or ½ round bur is used to remove decalcified enamel

 Sealant is placed

Type-B

 Incipient lesion in dentin is small & confined

 Local anesthesia is not required

 An appropriate base is placed in areas of dentin exposure ,composite resin is placed

and remaining pit and fissures sealed with a sealant

 Type -C

 More extensive dentinal involvement and requires restoration with

posterior composite material

 Appropriate base is applied over dentin

 Pit and fissures are covered with a sealant

 Local anesthesia is required

CONCLUSION

 The cariostatic property of sealants are attributed to the

physiological obstruction of the pit and fissures this prevents the
penetration of fermentable carbohydrates and so remaining bacteria
cannot produce acid in cariogenic concentrations
 Educating patients and parents on the importance of dental sealant is
critical.
 The fact that pits and fissures sealants are safe and effective should
justify their routine use as a preventive measure
REFERENCES
 Dentistry For Child And Adolescent – Mc Donald

 Operative Dentistry - Sturdevant

 Textbook Of Pedodontics – Shobha Tandon

 Textbook Of Preventive And Community Dentistry- Soben Peter

 Simenson Pediatric Dentistry – 24:5, 2002

 European Archives Of Paediatric Dentistry 13 (Issue 2). 2012

 Journal Of Indian Society Of Pedodontics And Preventive Dentistry 2011

DCNA-2005

Text book of Minimal intervention Dentistry-wilson

JADA-2000,2005,2008

EAPD guidelines for the use of pit and fissure sealnats ,europian journal of pediatric dentistry;3,2003.