**Pit and Fissure Sealants** --- **Outline** - Introduction - History - Ideal sealant material - Indications for sealants - Material type - Sealant placement technique - Approximal sealing --- **Pit and Fissure** **Pit** - A small pin point depression located at the junction of developmental grooves or at terminals of those grooves **Fissure** - It is a narrow channel, groove, cleft, ditch or crevice which may be sometimes deep - It is formed at the depth of developmental grooves during the development of the tooth - (or) deep clefts between adjoining cusps --- **Pit and Fissure** - Tooth surfaces with pits and fissures are particularly vulnerable to caries development (Manton and Messer, 1995) - Although the occlusal surfaces represented only 12.5% of the total surfaces of the permanent dentition, they accounted for almost 50% of the caries in school children (Ripa, 1973) - The plaque accumulation and caries susceptibility are greatest during the eruption of the molars (Carvalho et al. 1989)       **Pit and Fissure Sealant** • Toothbrush bristles are sometimes too big to enter and clean pits & fissures • Approximately 90% of carious lesions found in the pits and fissures of permanent posterior teeth **The form of Pit and Fissure** Pits and fissures can be classified into the following forms: **V-type (34%)** • wider at top & narrow at bottom • shallow • self cleansable • somewhat caries resistant • non-invasive techniques Nagano 1961 **The form of Pit and Fissure** **U-type (14%)** • almost the same width from top to bottom • shallow • self cleansable • somewhat caries resistant • non-invasive techniques Nagano 1961 **The form of Pit and Fissure** **I-type (19%)** • an extremely narrow slit opening (quite constricted) • may resemble a bottle neck • depth of fissure may be close proximity to the DEJ • plaque retentive • mechanical plaque removal is difficult • caries susceptible Nagano 1961     **The form of Pit and Fissure** **IK-type (26%)** • extremely narrow slit associated with a large space at the bottom as it extend towards DEJ • may have a number of different branches • caries susceptible Nagano 1961 **The form of Pit and Fissure** **Inverted Y (7%)** • narrow slit like opening large base as it extend towards DEJ • may have a number of different branches • caries susceptible Nagano 1961 **Pit and Fissure Sealant** **Definition** A fissure sealant is a material that is placed in the pits and fissures of teeth in order to prevent or arrest the development of dental caries (Weibury et al. 2004) **Pit and Fissure Sealant** • Sealants are non-invasive • Sealants can be placed for two main reasons: - to **PREVENT** dental caries initiation - to **ARREST** caries progression i.e. used as preventive and therapeutic treatment   **How do Sealants work?** •  Sealant provide a physical barrier between the sealed area of the tooth and the microorganisms in the mouth •  Sealants make it easier to clean area via tooth brushing or mastication •  Keep substrates out of pits, fissures and grooves ➤ **Effectiveness of sealants is dependent upon their long term** retention **History** 1895 Wilson Used zinc phosphate cement 1905 Miller Application of silver nitrate 1923 Hyatt Prophylactic odontotomy 1929 Bodecker Fissure eradication 1942 Kline & Knutson Ammonium silver nitrate 1955 Buonocore Advocated bonded resins-acid etching (concentrated phosphoric acid) 1962 Bowen Introduced BIS-GMA material **History** **70** PREVENTIVE DENTISTRY. BY I. P. WILSON, D. D. S., BURLINGTON, IOWA. The imperfectly developed enamel in these fissures is sometimes mistaken for caries, and is treated accordingly. Instead of attempting excavation in such cases, let the fissures be thoroughly cleaned, washed with an astringent fluid to dehydrate with alcohol, dry thoroughly, and fill with cement. Then place a little of the dry powder over the filling and press it firmly with the finger, forcing the cement into the remotest recesses of the fissures, and excluding the moisture, if necessary, with the finger still upon the filling, and holding it there until crystallization has taken place. Then dress off the surplus, and in nine cases out of ten decay has been prevented, and without causing any pain from excavation. Wilson IP. Preventive dentistry. Dent Dig. 1895;1:70-72 **History** Prophylactic Odontotomy: The Cutting into the Tooth for the Prevention of Disease. BY THADDEUS P. HYATT, D.D.S., Brooklyn, N.Y. - Hyatt TP. Prophylactic odontotomy: the cutting into the tooth for the prevention of disease. Dent Cosmos 1923;65:234-241   **History**  Bodecker, C. F. (1929). "The eradication of enamel fissures." Dent Items Int 51: 859. --- **History**  Bodecker, C. F. (1929). "The eradication of enamel fissures." Dent Items Int 51: 859. --- **History – Development of Sealant Material**  Kline H, Knutson JW. Studies on dental caries XIII. Effect of ammoniacal silver nitrate on caries in the first permanent molar.* --- **History -**  Buonocore MG. A simple method of increasing the adhesion of acrylic filling materials to enamel surfaces. J Dent Res. 1955;34:849-853.      Reduction in Occlusal Caries Incidence •  Sealants have been shown effective in reducing occlusal caries incidence in first permanent molars –  **76.3%** at four years –  **65%** at nine years from initial treatment –  no reapplication in the last five years (Bravo M et al. Sealant and Fluoride Varnish in Caries: a Randomized Trial. J Dent Res 2005;84 12):1138- 1143.) Properties of an Ideal Sealant Material •  Non-toxic and non irritating •  Biocompatibility with oral tissues •  Free-flowing low viscosity material •  Capable of entering narrow fissures •  Low solubility in the oral environment •  Sustained bonding to enamel •  Cariostatic action •  Simple application by dentist / hygienist Indications •  High caries risk patients •  Deep, narrow fissure patterns •  Deep, inaccessible pits of permanent molars •  Deep palatal and buccal pits •  Invaginations on anterior teeth •  Patients with special health care needs •  Patients with limited manual dexterity Types of Sealants Based on Material Glass ionomer cements Resin based materials Conventional Resin modified Autopolymerised Photopolymerised Combination of two process  **Glass Ionomers Sealants** **Advantages** - Generally easier to place - Not as moisture sensitive - Bond to the tooth structure - Fluoride release **Glass Ionomers Sealants** **Indications** - When moisture control is difficult to achieve - GIC can be used as an interim preventive measure until resin based sealant can be placed e.g. until adequate moisture control is achievable - Partially erupted teeth - Developmental defects of enamel - hypomineralised / hypoplastic teeth **Glass Ionomers Sealants** **Glass Ionomers Sealants** - Studies on the use of GCAs fissure sealant indicate significantly lower retention rates than resin-based ones (Raadal et al., 1996; Boksman et al. 1987; Forss et al. 1994) - Some studies showed that GICs exert a cariostatic effect even after they disappeared macroscopically - this effect might be based on remnants of the cement in the fissure as well as increased levels of F on the enamel surface (Williams and Winter, 1981; Shimokobe et al. 1986) - Limited and conflicting evidence that GIC reduces caries incidence in permanent teeth (Pardi et al., 2003; Pereira et al. 2003; Poulsen et al. 2006)   **Resin based Fissure Sealants** • Resin based fissure sealants are bonded to the underlying enamel by the use of the acid etch technique • Their caries preventive property is based on the establishment of a tight seal, which prevents leakage of nutrients to the microflora in the deeper parts of the fissure • The resin sealants may be either pure resin composites or compomers, and their polymerisation may be initiated chemically or by light **Resin Fissure sealants** **Resin based Fissure Sealants** Resin based Fissure Sealants Mickenautsch and Yengopal 2016 **Examination** • Visual examination - ICDAS visual assessment protocol • Tactile examination - a sharp dental explorer used for detection/diagnosis of occlusal caries is contraindicated • Radiographic examination - occlusal carious lesions rarely visible radiographically until there is significant dentine demineralization      **Technique For Sealing** • Isolation • Surface cleaning (Prophylaxis) • Etching • Washing and drying • Application o Evaluation o Adjustment • Recall and maintenance for sealants **Isolation** • Inadequate moisture control is the primary reason for sealant loss • Resin-based sealants are hydrophobic and require isolation that assures no salivary contamination • Isolation may be accomplished using - Rubber dam - Cotton rolls - Dry angles/dri-aides - Parkell dry-field mouth prop - The isolite or Isodry - Blue Boa **SCORE** **Score** **0** ***SOUND*** Opacity with air-drying: WHITE, BROWN **Scores** **1** **1B** 1W 2B **Scores** **2** ***SOUND*** **Score** **3** ***OPACITY*** without air-drying: WHITE, BROWN **Score** **4** ***UNDERLYING*** GREY SHADOW ***SURFACE*** **INTEGRITY** ***LOSS*** **Score** **5** ***DISTINCT*** **CAVITY** **Score** **6** ***EXTENSIVE*** **CAVITY** **Technique For Sealing** **Time to seal** **• There is good evidence that teeth sealed very early after eruption require more frequent reapplication of the fissure sealant than teeth sealed later (Dennison et al., 1990; Walker et al., 1996)** **• Therefore, fissure sealant placement may be delayed until the teeth are fully erupted, unless high caries activity is present** **• Placement of fissure sealant even in the absence of regular followup is beneficial (Cueto and Buonocore, 1967; Chestnutt et al. 1994)**       **Isolation** • Cotton rolls (Garmers clamp) • Rubber Dam - when properly placed, provides the best, most controllable isolation - discomfort during clamp placement - need for local anaesthetic? **Cotton rolls Vs rubberdam** • provide comparable retention rates (Lygidakis et al. 1994) --- **Technique For Sealing - Isolation** Rubber dam Cotton rolls Dry-guards Garmers Clamps Dry-angle Dry-guards --- **Isolation** Parkell dry-field mouth prop Isolite Blue Boa Blue Boa --- **Isolation** • Adequate isolation is the critical aspect of the fissure sealant outcome • If the enamel porosity created by the etching procedure is filled by liquid, the formation of resin tags in the enamel is reduced, and the resin is poorly retained • Salivary contamination during and after acid etching, allows the precipitation of glycoproteins onto the enamel surface, greatly decreasing bond strength to the FS (Silverstone, 1984; Donnan and Ball, 1988) • If this occurs, re-etching is needed           **Surface cleaning (Prophylaxis)** • The need for surface cleaning and the method of cleaning pits and fissures prior to fissure sealant placement may seem to be controversial • Raadal et al. 2001 suggests careful removal of plaque and pellicle by the use of pumice or air-polishing instruments in order to obtain optimal acid-etch pattern of the enamel • Harris and Garcia-Godoy, 1999 maintains that the effect of acid etching alone is sufficient for surface cleaning provided obvious soft material has been removed **Scanning electron microscope photograph illustrating debris and pellicle on the cuspal slopes of a molar tooth** **Use of Pumice for Prophylaxis** • Pumice is used to remove enamel pellicle and organic debris, and to enhance bonding • Taylor & Gwinnett (1973) showed that pumice still remained within the fissure system when it was used to remove surface organic debris • Asquinazi et al. 1999 used radioactively labelled pumice and showed that some of the pumice used in the prophylaxis retained within the fissure system even after a 60 sec wash, or the combined action of etching for 30 sec followed by a 30 sec wash • Gwinnett & Buonocore, 1972 showed that pumice deposits in the pits and fissures would adversely influence resin penetration • Donnan & Ball, 1988 concluded that pumice prophylaxis unnecessary **Pumice for Prophylaxis (Burrow et al. 2003)** Montage of molars showing the negative images of the fissure systems. **Pink:** sealant; **blue:** prophylaxis material; clear layer: organic material **Etching** • The goal of etching is to produce an uncontaminated, dry, frosted surface (Manton and Messer, 1995) • Acid etching kills 75% of bacteria in the fissures (Theilade et al. 1977 ) • Frequently used etchant is orthophosphoric acid (concentration between 30% and 50% by weight) • Duggal et al. (1997) showed no significant difference in retention of fissure sealants after one year follow-up on second primary and first permanent molars when 15, 30, 45 or 60 seconds etching times were used  **Washing and Drying** • Tooth irrigated vigorously with air and water for about 30 sec • Dried with uncontaminated compressed air for 15 seconds (Manton and Messer, 1995) • Water under pressure in air-water spray with suction • Suction tip placed above/adjacent the tooth • The exact washing and drying times are not as important as ensuring that both washing and drying are thorough enough to remove all etchant from the surface of the tooth to give a chalky, frosted appearance (Waggoner and Siegal, 1996) **Etched, Washed & Dried Tooth Surface**  Etched tooth surface – dried frosted surface **Bonding Agent** • Feigal et al. 1993; 2000 showed when a single-bottle bonding system was used as a layer between enamel and sealant: – decreased risk of failure of occlusal sealants by 47% – reduced the risk of failure of buccal/lingual sealants by 65% • Buccal and lingual surfaces are subject to continuous flexure in the process of mastication. Bonding agent provides a stress-breaking effect and improves sealant bond (Feigal et al. 2000) **Bonding Agent** • Bonding agent reduces the saliva’s effect on sealant microleakage • Useful where moisture control is difficult to achieve especially for buccal and lingual surfaces **Bond strength failure:** potential contaminants – moisture – organic debris – blood – salivary pellicle – oil from air compressors / handpiece  **Etchants & Conditioners** **Application of Fissure Sealant** A flowable composite resin has been used and is spread into the fissures with a ball- **burnisher** **Cured Fissure Sealant** Light cured composite resin **Evaluation – Finishing and Polishing** Finishing Finishing Finishing **cup** disc point Coarse Medium Fine Super fine           **Follow up and Maintenance** • All sealed surfaces should be regularly monitored both clinically and radiographically • Radiographs should be taken at a frequency consistent with the patient’s risk status • Even under proper application conditions, 5-10% of sealants can be expected to fail annually (Yazici et al. 2006) • Defective or lost fissure sealants should be repaired when deficient (if they are to be effective) - provided the surface is caries free • **"In practice sealants are not made to be applied once"** Ripa, 1985 **Sealants for preventing dental decay in the permanent teeth (Review)** Ahovuo-Saloranta A, Forss H, Walsh T, Hiiri A, Nordblad A, Makela M, Worthington HV **Objectives** To compare the effects of different types of fissure sealants in preventing caries in permanent teeth in children and adolescents (Ahovuo-Saloranta A et al. Sealants for preventing dental decay in the permanent teeth. Cochrane Database of Systematic Reviews 2013, Issue 3. Art. No.: CD001830.) **Ahovuo-Saloranta A et al. 2013** **Authors’ conclusions** • The application of sealants is a recommended procedure to prevent or control caries • Sealing the occlusal surfaces of permanent molars in children and adolescents reduces caries up to 48 months when compared to no sealant, after longer follow-up the quantity and quality of the evidence is reduced • The review revealed that sealants are effective in high risk children • The relative effectiveness of different types of sealants has yet to be established **Resin based Fissure Sealants - Safety** • During the mid-1990s safety concerns were expressed regarding leaching of bisphenol-A (BPA) and bisphenol-A dimethacrylate (BPA-DMA) from FS, and a possible oestrogenic effect • Soderholm and Mariotti (1999) concluded that the short term risk of oestrogenic effects from treatments using bispenol-A based resins is insignificant • Fung et al. 2000 showed that BPA released orally from a dental fissure sealants may not be absorbed at all or may only be present in non-detectable amounts in the systemic circulation • A systematic review of pit and fissure sealants (Azarpazhooh, 2008) also states that, “**The evidence suggests that patients are not at risk for exposure to BPA from the use of dental sealants**”  Sealing of Carious Fissures • Several studies have shown that resin fissure sealants are able to stop further progression of carious lesions in pits and fissures, and even in dentine lesions (Mertz-Fairhurst et al., 1986; Handelman, 1991; Oong et al. 2008; Griffin et al. 2008) • The rationale for this approach is that the placement of a fissure sealants isolates the carious lesion from the surface biofilm • The use should be limited to fissures where the lesion seems to be confined to the enamel, and that dentine lesions should be restored, preferably by the use of minimal intervention techniques, such as the preventive resin restoration (Waggoner and Siegal, 1996; Workshop on Guidelines for Sealant use: recommendations, 1995) (Welbury et al. 2004; Eggertsson, 2013; Ricketts D, et al. Operative caries management in adults and children. Cochrane Database of Systematic Reviews 2013, 3: CD003808) Preventive Resin Restoration - PRR • It utilizes adhesives restorative material in conjunction with sealants. • Caries is removed a restoration is placed and adjacent pits and fissures are sealed at the same time Thank you