12. pit and fissure sealants

detailed explanation on placement

1. Pit and fissure sealant : An Updating Technique CHAITANYA.P III MDS Dept of Public Health Dentistry

2. Contents Introduction History Definition Morphology Requirements of materials Materials used Classification Indications & Contraindications Age period for sealant placement Application Advantages & Disadvantages Recent advances Conclusion References 2

3. Introduction Dental caries causes demineralization & destruction of hard tissues of the tooth, anatomical pits & fissures of the teeth are susceptible areas for initiation of this dental caries. There are several preventive & prophylactic methods advocated such as regular oral hygiene practices and interventions, dietary modifications, pit & fissure sealants, preventive resin restoration to avoid dental caries. ‘Prevention is better than cure’ 3

4. History Years Authors Contribution 1895 Wilson Placement of zinc phosphate cement in pits and fissures 1923 Hyatt Prophylactic odontomy 1942 Kline and Knutson Treatment with ammoniacal silver nitrate 1955 Buonocore Sealing of pits and fissure with bonded resin material 1971   Pit and fissure sealant recognized by ADA 1972 Nuva seal first commercial sealant 1978 Simonson Preventive resin restoration 1986 Garcia-Godoy Preventive glass ionomer restoration 4 Ref: Norman O.Harris . Primary preventive dentistry, 2014; 8 th edition; pearson publisher, pg:274. George Babu et al Pit and fissure sealants in pediatric dentistry. SRM Journal of Research in Dental Sciences,2014; 5(4):253-257.

5. Definition Pit: - A small pinpoint depression located at the junction of developmental grooves or at terminals of those grooves. Fissures: - Deep clefts between the adjoining cusps. They provide areas for retention of caries producing agents. According to Simonsen : Material that is introduced into the pits & fissures of caries susceptible teeth thus forming micromechanically bonded protective layer cutting access of caries producing bacteria from their source of nutrients. According to ADA An adhesive material that is applied to pits & fissures of teeth in order to isolate from rest of the oral cavity. 5

6. Morphology Two main types of pit & fissures 1) Shallow , wide v – shaped fissures Self-cleansing Caries resistant 2 ) Deep , narrow I – shaped fissure Constricted Resemble a bottle neck: Extremely narrow slit like opening Large base towards DEJ Caries susceptible Number of different branches 6

7. According to Nango (1960) There are 5 types of fissures based on the alphabetical description of shape they are V type U type I type K type H shaped fissures-seen mostly in premolars. Susceptibility of caries is related to form and depth of these pits and fissures. The shallow wide V and U shaped fissures tend to be self-cleansing and somewhat caries resistant. Deep narrow I shaped and K shaped fissures are quiet constricted and resemble a bottle neck. 7

8. Requirements of materials used as sealants Reduced water sorption & solubility. Increased hardness & abrasion resistance after curing. Sufficient strength, surface hardness, dimensional stability. Good flow. Short setting time & adequate working time. Same thermal conductivity as tooth. Good bond strength with enamel. Chemically inert, anti-cariogenic. Low volatility. Reduced polymerization shrinkage. 8

9. Materials used Cyanoacrylates: They polymerize to hard & brittle polymers on etched tooth surface in presence of moisture. Mechanical durability is not satisfactory & they are not biodegradable. Polyurethanes: Not regularly used due to poor mechanical properties, oral durability & toxicity . Eg : Epoxylite . 9

10. Dimethacrylates : MMA is highly volatile & lack penetration. Enamite , BISGMA are also used.   Glass Ionomer ; Developed by McLean & Wilson. Hydrophilic, good adhesion, biocompatible. Used for fissures exceeding 100micrometres 10

11. Classification Based on curing method : . Generation Curing Method First generation Ultraviolet light 350nm for polymerization, UV light prevents complete polymerization. Second generation Self-cured or chemically cured. Most are unfilled. Filled resins have increased abrasion resistance. Third generation Visible light cured of 430-490nm. Fourth generation Fluoride releasing sealants Fifth generation Glass ionomer cement as pit and fissure sealants. Sealants with bonding agents. Sixth generation Self-etching light cured sealants. 11

12. B. Based on presence of filler: Unfilled-better flow. Filled: strong & resistant to wear . C. Based on appearance or colour: Transparent Opaque Clear , pink or Tooth coloured or white Amber coloured Colour changes during or after polymerisation 12

13. D. Based on fluoride release Fluoride releasing sealants Non- Fluoride releasing sealant E. Types of sealants * Glass ionomer cement sealants sealants with bonding agents Self-etching light cured sealants Fluoride releasing sealants Moisture-resistant sealants Colored versus clear sealants 13 * Ref: Norman O.Harris . Primary preventive dentistry, 2014; 8 th edition; pearson publisher, pg:273-283.

14. Criteria Indications Contraindications Tooth age   Recently erupted   Teeth remains caries free for 4 or >4 years Tooth type   Molar   Premolar except when caries risk is high Occlusal morphology Deep narrow retentive pit and fissures Narrow wide self cleansing pit and fissures Status of proximal Surface Sound Carious General caries activity Many occlusal lesions few proximal lesions Many proximal lesions Other preventive measures Patient receiving approach systemic and topical F therapy and are still caries a ctive     Indications and contraindications 14

15. Age period for sealant placement The disease susceptibility of the tooth should be considered when selecting teeth for sealants not the age of the individual.   Ages 3 and 4 years are the most important times for sealing the eligible deciduous teeth. Ages 6-7 years for the first permanent molars. Ages 11-13 years for the second permanent molars and premolars. 15

16. Application of pit and fissure sealant 1. Cleaning the pit and fissure surfaces   Plaque and debris might interfere with the etching process or sealant penetration. Historically, it has been advocated to clean the surfaces with bristle brush and pumice. Use of prophylactic pastes, especially those with fluoride, have been discouraged because it was thought that the fluoride might make the enamel surface less reactive to the etchant and thereby reduce the bond strength. Air abrasion also has been suggested for preparation of the occlusal surface before sealant application. 16

17. S. Hatibovic-Kofman et al ( 1998) Conducted an in-vitro study to compare the microleakage of unfilled and filled sealants after conventional(pumice with rubber cup), bur, and air-abrasion tooth preparation. The study results showed there was no statistically significant difference in retention of sealant with regard to technique of tooth preparation before sealant placement. 17 S. Hatibovic-Kofman , GZ Wright, Ian Braverman . Microleakage of sealants after conventional, bur, and air-abrasion preparation of pits and fissures. Am Acad pediatr Dent, 1998; 20(3) :173-76.

18. Julie A. Blackwood et al ( 2002) conducted an in vitro study to evaluate the microleakage of pit and fissure sealants after using three different pit and fissure preparation techniques: (1) traditional pumice prophylaxis and acid etching, (2) fissure enameloplasty and acid etching and (3) air abrasion and acid etching. The study results showed that specimens treated with traditional pumice prophylaxis had higher amount of microleakage compared to other techniques. 18 Ref: Julie A. Blackwood, MS Diane C. Dilley, Michael W. Roberts, Edward J. Swift. Jr. Evaluation of pumice, fissure enameloplasty and air abrasion on sealant microleakage . Pediatr Dent, 2002; 24(3).

19. 2. Isolation of the tooth   Adequate isolation is the most critical aspect of the sealant application process. Salivary contamination of a tooth surface during or after acid etching will have a deleterious effect on the ultimate bond between enamel and resin. The rubber dam, when properly placed, provides the best, most controllable isolation, and for an operator working alone, it ensures isolation from start to finish. Cotton roll isolation offers some advantages over rubber dam isolation. 19 WF Waggoner and M Siegal . Pit and fissure sealant application: An updating technique. J Am Dent Assoc , 1996; 127: 351-361.

20. 3. Etching Introduction of acid etch technique has made the sealing of occlusal surfaces more effective. The most critical step in sealant application technique is acid conditioning or acid etching procedure. Etching enhances the tooth’s receptivity to bonding with the sealant. During this critical step, meticulous maintenance of a dry tooth surface is essential for bonding to be successful. The conventional 60 s etching was first used by Ripa and Cole. Increased etching time for deciduous teeth is attributed to various reasons like: Deciduous teeth have less mineral and more organic material in the enamel. Deciduous teeth have a larger internal pore volume and thus more exogenous organic material . 20

21. Deciduous teeth have more prism less enamel on their surface than do permanent teeth. The prism rods in deciduous teeth approach the surface at a greater angle and thus are more difficult to etch. Three characteristic etching patterns occur following exposure of sound enamel to phosphoric acid. Type 1 etching pattern: Prism cores lost but Prism peripheries remain — honeycomb appearance. Type 2 etching pattern: Prism peripheries are lost, Prism cores appear to be relatively intact — cobble stone appearance. Type 3 etching pattern: Some regions of etched enamel show a generalized surface roughening and porosity with no exposure of prism cores or peripheries. 21

22. The enamel surface shows a mainly aprismatic or prismless configuration. Due to phosphoric acid etching and subsequent water-rinsing of the etched enamel, the prismless enamel surface layer is removed. Thereby the prismatic structured enamel is exposed providing sufficient micro-retentive bonding of the fissure sealant. 22 Gwinnet AJ. The ultrastructure of the ‘ prismless ’ enamel of permanent human teeth. Arch Oral Biol,1967;12: 381—8 . Gwinnett AJ. Human prismless enamel and its influence on sealant penetration. Arch Oral Biol,1973;18:441-444. Kodaka T, Kuroiwa H, Higashi S. Structural and distribution patterns of surface prismless enamel in human permanent teeth. Caries Research, 1991;25:7—20. Kanemura N, Sano H, Tagami J. Tensile bond strength to and SEM evaluation of ground and intact enamel surfaces. J Dent, 1999;27:523-30 . Hannig M, Bock H, Bott B, Hoth-Hannig W. Inter-crystallite nanoretention of self-etching adhesives at enamel imaged by transmission electron microscopy. Eur J Oral Sci , 2002;110:464—70 . Reference

23. 4. Thoroughly rinse and dry the tooth Many of the sealant manufacturers recommend rinsing the tooth for 20-30 s to remove the etchant. An exact rinse time is probably not as important as ensuring that the rinse is long enough and thorough enough to remove all of the etchant from the surface. Drying the tooth with compressed air is likewise done not for a specific time but rather for a specific result. A tooth that is completely dried will exhibit a chalky, frosted appearance. 23

24. 5. Application of sealant During sealant application, all the susceptible pits and fissures should be sealed for maximum caries protection. This includes buccal pits of mandibular molars and lingual grooves of maxillary molars. The sealant material can be applied to the tooth in a variety of methods. Some common problems occur during sealant application, Small bubbles may form in the sealant material. If these are present, they should be teased out with a brush before polymerization. Unfilled sealants have a low viscosity that makes them prone to pooling in the distal pit area of maxillary molars due to patient position and gravity. This can be rectified by applying the sealant judiciously or by removing excess amounts with a brush. 24

25. 25 Chosack and Eidelman (1988) found that the longer sealants were allowed to sit on the etched surface before being polymerized, the more the sealant penetrated the microporosities , creating longer resin tags, which are critical for micromechanical retention . Sealants in which polymerization was not initiated for 20 seconds after application had resin tags nearly three times longer than those of sealants that were polymerized after a five- or 10-second delay. C hosak A, Eidelman E. Effect of time from application until exposure to light on the tag lengths of a visible light-polymerized sealant. Dent Mater 1988;4:302-6.

26. 6. Evaluation The sealant should be visually and tactually inspected for complete coverage and absence of voids or bubbles. Attempts should be made to dislodge the sealant with an explorer. If the sealant is dislodged, the tooth should be carefully inspected to see that no debris has been left in the fissure, which may have interfered with the bond. Small voids in the sealant can be repaired simply by adding new material to the void and polymerizing. Some sealants will be completely or partially lost and will require reapplication. During routine recall examinations, it is necessary to re-evaluate the sealed tooth surface both visually and tactually for loss of material, exposure of voids in the material and caries development. The need for reapplication of sealants is usually highest during the first 6 months after placement. 26

27. * The unfilled sealant sections showed significantly less microleakage than filled sealants, regardless of the method of tooth preparation . 27 * S . Hatibovic-Kofman , GZ Wright, Ian Braverman . Microleakage of sealants after conventional, bur, and air-abrasion preparation of pits and fissures. Am Acad pediatr Dent, 1998; 20(3) :173-76 . ** The unfilled sealant showed significantly more retention than filled sealants. ** V . Rajashekar Reddy et al. Retention of resinbased filled and unfilled pit and fissure sealants: A comparative clinical study. Contemp Clin Dent. 2015 Mar; 6( Suppl 1): S18–S23.

28. The sealant effectiveness can be assessed by CCC sealant evaluation system CCC sealant evaluation system C – Colour : validity of sealant identification and caries diagnosis. C – Coverage : effectiveness of the sealant. C – caries: caries status on the surface. 28

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30. 30 Christopher Derry , A proposed method for assessing the quality of sealants-the CCC sealant evaluation system, J of CDOE, 2001,29; 83-91.

31. Codes for evaluation of sealant- Ana Luiza Falavinha VieiraI et al 2006 31

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35. Advantages It is a non-invasive technique. Sealing of pits & fissures prevents tooth decay. Fluoride release from fluoridated sealants can confer protection to adjoining areas. Sealants can be used at the community level for prevention of caries. Disadvantages Adverse reaction- allergy to resin ( Hallstrom , 1993) Caries susceptibility of etched enamel. Economic feasibility. Inadvertent placement over carious sites. Detection of lost sealant. Technique sensitivity. 35

36. Recent advances in pit and fissure sealants 1 . ACP-pit & fissure sealants. ( Amorphous calcium phosphate sealant ) Eg : Bosworth Aegis pit & fissure sealants 36

37. 37 Zawaideh FI, Owais AI, Kawaja W. Ability of pit and fissure sealant-containing amorphous calcium phosphate to inhibit enamel demineralization. Int J Clin Pediatr Dent 2016;9(1):10-14. Feda I Zawaideh et al (2016) conducted an in-vitro study on 75 extracted non-carious third molars sealaed with resin-based sealant (Concise™), ACP-containing sealant (Aegis®) or fluoride-containing sealant ( Conseal -F™ ). The results showed that The ACP-containing pit and fissure sealant has the potential to inhibit enamel demineralization.

38. 2. Moisture tolerant pit & fissure sealants. Eg : Pulpdent Embarce wet bond Traditional sealents Hydrophobic They repel water and cannot be applied where there is Moisture. Bis -GMA is present. ( hydrophobic monomer ) Filled or un-filled sealants Embrace wet bond Hydrophilc . Embrace is activated by moisture . Embrace WetBond contains no bis -GMA and no bisphenol A. It contains fillers (aluminum powder, carbon fiber, graphite, calcium carbonate, silica, clay) 38

39. The Hydrophillic sealant (79.6) showed significantly more retention than Hydrophobic sealants(73.4). 39 Akurathi Ratnaditya et al. Clinical Evaluation of Retention in Hydrophobic and Hydrophillic Pit and Fissure Sealants-A Two Year Follow-Up Study . Journal of Young Pharmacists 2015 ; 7( 3);171-179

40. 3. Etch- free light cured sealants. Eg : Beauti Fill sealant 4. Self-etching Self-adhesive sealant Eg : Maxcem ellite fill sealant   5 . Pen type handling of sealants. Eg : Ecuseal ( Ecu -PEN is autoclavable up to 130 °C. It will withstand 100 autoclave cycles .) 6. Nano composites as sealants. Eg : Transeal (Deep penetration and excellent flow rate) 40

41. Advances in curing of sealants U.V light cure (320-395nm) LED CURING LIGHT (440-490nm) Tungsten halogen curing light (400-500nm) Plasma Arc (400-500nm) LSAER (Light Amplification by Stimulated Emission Radiation ) Eg : Co2 laser improved retention of sealant (10600nm). Argon laser improved mechanical retention of sealant (488, 514nm). 41

42. Studies on Sealant Huda Nazar et al (2013) conducted a study on Effectiveness of Fissure Sealant Retention and Caries Prevention with and without Primer and Bond. Results showed that There was no difference between teeth sealed with primer and bond and teeth sealed without primer and bond retained sealant. 42 Huda Nazar et al. Effectiveness of Fissure Sealant Retention and Caries Prevention with and without Primer and Bond. Med Princ Pract 2013;22:12–17

43. Priscilla Santana Pinto Goncalves et al(2016) conducted a study Pit and Fissure Sealants with Different Materials: Resin Based vs Glass Ionomer Cement. Both the sealants, Fluroshield ( Dentsply ) and Clinpro TM Varnish® XT(GIC) were effective in preventing caries lesion within 6 months, although Fluroshield sealant showed better clinical retention. 43 Ref: Priscilla Santana Pinto Goncalves et al. Pit and Fissure Sealants with Different Materials: Resin Based x Glass Ionomer Cement – Results after Six Months .Brazilian Research in Pediatric Dentistry and Integrated Clinic 2016, 16(1):15-23

44. 44 Imran Pasha Mohammed et al (2016) conducted a study on Comparison of effectiveness of traditional acid etching and of the self‑etching agent in sealant retention: A randomized controlled trial. The study results showed that there was No significant difference was seen in the retention of fissure sealants placed on occlusal surfaces following the use of an traditional PAE technique and SE bonding agent , after 6 months. Mohammed IP, Jaleel BF, Hiremath SS, Manjunath C, Amarah U, Krishnamoorthy A. Comparison of effectiveness of traditional acid etching and of the self-etching agent in sealant retention: A randomized controlled trial. J Indian Assoc Public Health Dent 2016;14:4-9

45. Conclusion Caries is a problem for patients of all ages. Along with proper diet , fluoride, and biofilm control, pit and fissure sealants should be considered as part of an overall preventive program rather than an isolated procedure. 45

46. References Gwinnet AJ. The ultrastructure of the ‘ prismless ’ enamel of permanent human teeth. Arch Oral Biol,1967;12: 381—8. Gwinnett AJ. Human prismless enamel and its influence on sealant penetration. Arch Oral Biol,1973;18:441-444 . Simonsen RJ. Chapter 2: Pit and fissure sealants. In: Clinical Applications of the Acid Etch Technique. 1st ed. Chicago, IL: Quintessence Publishing Co, Inc ; 1978:19-42 . Chosak A, Eidelman E. Effect of time from application until exposure to light on the tag lengths of a visible light-polymerized sealant. Dent Mater 1988;4:302-6 . Kodaka T, Kuroiwa H, Higashi S. Structural and distribution patterns of surface prismless enamel in human permanent teeth. Caries Research, 1991;25:7—20. WF Waggoner and M Siegal . Pit and fissure sealant application: An updating technique. J Am Dent Assoc , 1996; 127: 351-361 . S. Hatibovic-Kofman , GZ Wright, Ian Braverman . Microleakage of sealants after conventional, bur, and air-abrasion preparation of pits and fissures. Am Acad pediatr Dent, 1998; 20(3) :173-76 . 46

47. 47 Kanemura N, Sano H, Tagami J. Tensile bond strength to and SEM evaluation of ground and intact enamel surfaces. J Dent, 1999;27:523-30. Hannig M, Bock H, Bott B, Hoth-Hannig W. Inter-crystallite nanoretention of self-etching adhesives at enamel imaged by transmission electron microscopy. Eur J Oral Sci , 2002;110:464—70. Julie A. Blackwood, MS Diane C. Dilley, Michael W. Roberts, Edward J. Swift. Jr. Evaluation of pumice, fissure enameloplasty and air abrasion on sealant microleakage . Pediatr Dent, 2002; 24(3 ). Ana Luiza Falavinha VieiraI et al; Evaluation of glass ionomer sealants placed according to the ART approach in a community with high caries experience: 1-year follow-up : J. Appl. Oral Sci,2006;14:4 Harshpriya et al, Recent trends in preventive dentistry-A review; SRM University dental journal, 2011;2(3):232-237 . Huda Nazar et al. Effectiveness of Fissure Sealant Retention and Caries Prevention with and without Primer and Bond. Med Princ Pract 2013;22:12–17

48. 48 Norman O.Harris . Primary preventive dentistry, 2014; 8 th edition; pearson publisher, pg:273-283. George Babu et al Pit and fissure sealants in pediatric dentistry. SRM Journal of Research in Dental Sciences,2014; 5(4): 253-257. V . Rajashekar Reddy et al. Retention of resinbased filled and unfilled pit and fissure sealants: A comparative clinical study. Contemp Clin Dent. 2015 Mar; 6( Suppl 1): S18–S23. Akurathi Ratnaditya et al. Clinical Evaluation of Retention in Hydrophobic and Hydrophillic Pit and Fissure Sealants-A Two Year Follow-Up Study . Journal of Young Pharmacists 2015 ;7( 3); 171-179 Priscilla Santana Pinto Goncalves et al. Pit and Fissure Sealants with Different Materials: Resin Based x Glass Ionomer Cement – Results after Six Months .Brazilian Research in Pediatric Dentistry and Integrated Clinic 2016, 16(1): 15-23

49. 49 19. Zawaideh FI, Owais AI, Kawaja W. Ability of pit and fissure sealant-containing amorphous calcium phosphate to inhibit enamel demineralization. Int J Clin Pediatr Dent 2016;9(1):10 20. Mohammed IP, Jaleel BF, Hiremath SS, Manjunath C, Amarah U, Krishnamoorthy A. Comparison of effectiveness of traditional acid etching and of the self-etching agent in sealant retention: A randomized controlled trial. J Indian Assoc Public Health Dent 2016;14:4-9.