2. 2
CARIES OF PIT & FISSURE:
⋇ Caries process particularly in 1st
& 2nd
molar starts as soon as it
erupts. Pit and fissure is an important factor in determining the
presence of caries.
⋇ According to BLACK - P&F don’t cause caries instead provide
a sanctuary to caries causing agents.
⋇ Pits &Fissure caries follows the direction of the enamel rods &
forms a shaped lesion with its apex at the outer surface and its
base towards DEJ.
⋇ It produces greater cavitations than proximal caries.
3. DEFINITIONS
PIT (Ash, 1993) - It is defined as a small pinpoint depression
located at the junction of developmental grooves or at terminals of
these grooves.
Fissure (Orbans, 1954) - Fissure is defined as deep clefts between
adjoining cusps.
Pit and Fissure Sealant (Simmonsen RJ, 1978) - Term used to
describe a material that is introduced into the occlusal pits and
fissures of caries-susceptible teeth, thus forming a
micromechanically-bonded, protective layer cutting access of
caries-producing bacteria from their source of nutrition.
Fissure Sealant (R Welbury, M Raadal, N Lygidaks, EAPD
Policy Document, 2003) – It is a material that is placed in the pits
and fissures of teeth in order to prevent or arrest the development of
dental caries.
3
4. HISTORY
1867 Arthur Stated that decay was invetible and that
Obliteration of the fissures could prevent its
occurence.
1905 Miller Used silver silver nitrate for fissure restoration
1922 Hyatt In his famous paper “Prophylactic Odontomy,” he
advocated filling the fissures of teeth with silver
or copper oxyphosphate cement as soon as the
teeth erupted and then later, when they were fully
into the mouth, preparing a small ocllusal cavity
and filling it with amalgam.
1939 Gore The use of polymers as fissure sealants and to a
lesser extent as coatings owes its origin to him as
had used solutions of cellulose nitrate in organic
solvents to fill the surface enamel made porous by
the action of acids in the saliva.
4
5. 1955 Buonocore Observed that, after treatment of the enamel
with concentrated phosphoric acid solution,
attachment of acrylic resin to tooth surfaces
was greatly increased.
1965 Gwinnett
and
Buonocore
Showed that an approximately 50%
phosphoric acid solution etched enamel and a
porosity resulted that was penetrated by the
cyanoacrylate, with production of a strong
bond.
1965 Bowen BIS-GMA was developed at the National
Bureau of Standards from the adduct of bis-
phenol A and glycidul methacrylate.
5
6. 1966 Cueto and
Buonocore
Initiated critical studies fissure sealing using a
methyl cyanoacrylate monomer filled with
silicate filler that had the potential through
polymerization of the cyanoacryklate of both
bonding to the enamel ( possibly) releasing
some fluoride fron the silicate filler. They
reported an 86.3% reduction in the incidence
of caries in the pits and fissures of permanent
molars and premolars over a 1 year period and
an 85.6% reduction after 2 years. Thus, the
principal of reduation of fissure caries by
obliteration of the fissure was established.
1968 Rodyhouse Reported on the use of BIS-GMA monomer
using methyl methacrylate as diluents together
with a peroxide amine polymerization system.
6
7. 1970 Buonocore Utilized BIS-GMA system but employed an
ultraviolet-sensitive polymerization initiative
(Benzoin methyl ether), which allow more
flexibility in the clinical application of the
material to the teeth and more complete filling
of the fissures.
1971 Nuva-Seal First pit and fissure sealant developed and
commercially introduced by LD CAULK
Company.
7
8. MORPHOLOGY OF PITS AND FISSURES
The fissure contains organic plug composed of reduced enamel
epithelium, microorganism forming dental plaque and oral debris.
The increased susceptibility of this surface to caries is due to the
fact that fissure provides a protected niche for plaque accumulation
( Rohr et al. 1991, Hicks 1986).
Recently erupted teeth have a porous enamel lining and the fissures
are rich in cellular and organic debris.
Theoretically this porous zone of enamel bordering the fissures
offers a 3-D honeycombed structure into which fissure sealants
could be locked.
8
9. Any procedure must be carried out at the earliest possible time
after eruption to make
effective preventive use of fissure sealants.
The penetration of liquids into cracks and crevices is given by the
equation of bikerman
z = Depth of the crevice; s = Width of the crevice
y = Surface tension of the liquid
ϴ = Advancing contact angle of the liquid
ɳ = Viscosity; t = Time 9
10. 10
Rationale
Why are sealants necessary ?
By nature of their anatomy, pit and fissure surfaces are often
difficult toclean and thus at higher risk for caries.
As illustrated in the magnification of
an occlusal tooth surface crosssection,
this deep and tortuous anatomy lends
itself to the entrapment of food debris,
Plaque formation and bacterial growth.
The illustration shows that the fissure is
so small that a toothbrush bristle will not reach the depth of the
fissure. Thus, even excellent home care efforts may not
be successful in cleaning a deep fissure.
11. 11
Another concern with pits and fissures is related to their
susceptibility to fluoride protection.
Research demonstrates that topical fluorides are less effective in
protecting the pit and fissure surfaces than the smooth surfaces of
enamel.
This does not imply that fluorides are ineffective on pit and fissure
surfaces; however, topical fluorides selectively benefit the smooth
surfaces to a greater extent than pit and fissure surfaces and this
difference is believed to be related to tooth anatomy.
The rationale for sealants is documented further by considering
those surfaces that are most at risk for dental decay.
12. 12
Epidemiological investigations confirm that the occlusal surfaces
alone account for well over 50% of the caries in children ages 6-18.
This percentage is particularly dramatic when one considers that the
occlusal surfaces represent only 12.5% of the tooth surfaces.
To underscore the problem of pit and fissure decay further, recent
studies show that over 90% of new carious lesions are confined to
pits and fissures; thus, if sealants are used in all developmental
fissures including facial pits and lingual fissures, significant decay
reductions are possible.
13. TYPES OF PITS AND FISSURES
There are 5 types of pits and fissure according to NAGANO (1961)
1) V - Type 2) U - Type
3) I - Type
13
15. HISTOPATHOLOGY OF FISSURE CARIES
First evidence of lesion formation occurs at the orifice of the fissure
and is represented by two bilateral lesions in enamel on opposite
cuspal inclines
Lesion progresses and depth of fissure wall becomes involved
Two lesions coalesce into one at the base of fissure
The enamel at the base is affected and lesion spreads laterally along
the enamel adjacent to the depth of fissure towards dental-enamel
juction (DEJ)
Cavitation occurs owing to lose of mineral and structural support
from affected enamel and dentin resulting in a clinically detectable
lesion 15
16. 16
TYPES OF PIT & FISSURE SEALANTS
The 1st
pit & fissure introduced was an UV Light activated sealant,
Nuva-Seal.
Pit & Fissure sealants are classified into 5 types:-
1)According to the chemical structures of monomers used.
2)Based on generations.
3)Based on filter content.
4)Based on color.
5)Based on curing.
17. 17
1) According to the chemical structures of monomers used
# Methyl Methacrylate (MMA).
# Triethylene glycol dimethacrylate (TEGDM).
# Bis phenol dimethacrylate (BPD).
# Bis-GMA is the reaction product of Bis-phenol A and Glycidyl
methacrylate (GMA) with a methyl methacrylate monomer.
# ESPE monomer.
# Propyl methacrylate urethane (PMA).
18. 18
2) Based on Generations :-
# 1st
Generation sealants :
- Polymerized with UV Light with wavelength of 356 μm.
- Had excessive absorption and incomplete polymerization of
sealant at its depth.
- Eg..... Nuva-lite (Caulk/Dentsply)
# 2nd
Genaration sealants :
- Self cure or chemical cure resins.
- Based on accelerator catalyst system.
- Eg..... Concise White (3M)
# 3rd
Genaration sealants :
- Light cured with visible (blue) light of 430-490 μm.
- Eg..... Helioseal
# 4th
Genaration sealants :
- Fluoride releasing sealants.
- Eg..... Seal right (Pulpdent)
19. 19
3) Based on filter content
# Unfilled
- Better flow and more retention but, abrade rapidly.
# Filled
- Resistance to wear but, may need occlusal adjustments.
4) Based on color
# Clear
- Esthetic, difficult to detect in recall visit.
- Eg..... Helioseal (changes from green to white).
# Tinted/Opaque
- Can be identified.
- Eg..... Delton
20. 20
# Colored
- Based on color change technology.
- Easy to see during placement and recall.
- Eg..... Clinpro pink ( changes to pink on setting).
5) Based on curing
# Autopolymerizing.
# Light cure.
22. 22
AAPD GUIDELINES (REVISED 2008)
1. Sealants should be placed into pits and fissures of teeth based upon
the patient’s caries risk, not the patient’s age or time lapsed since
tooth eruption.
2. Sealants should be placed on surfaces judged to be at high risk or
surfaces that already exhibit incipient carious lesions to inhibit lesion
progression. Follow up care, as with all dental treatment, is
recommended.
3. Sealant placement methods should include careful cleaning of the
pits and fissures without removal of any appreciable enamel. Some
circumstances may indicate use of a minimal enameloplasty
technique.
4. A low-viscosity hydrophilic material bonding layer, as part of or
under the actual sealant, is recommended for long-term retention and
effectiveness.
5. Glass ionomer materials could be used as transitional sealants.
23. 23
1. A viscosity allowing penetration into deep and narrow
fissures even in maxillary teeth.
2. Adequate working time
3. Rapid cure
4. Good and prolonged adhesion to the enamel
5. Low sorption and solubility
6. Resistence to wear
7. Minimum irritation to tissues
8. Cariostatic action
IDEAL REQUISITES OF AN EFFICIENT
SEALANT (Brauer, 1978)
24. 24
INDICATIONS
∂ Deep, retentive pits and fissures, which may
cause wedging of an explorer.
∂ No radiographic or clinical evidence of
proximal caries.
∂ Questionable enamel caries in pit and fissure.
∂ Newly erupted 1 M & permanent PM & M – with complete⁰
recession of pericoronal operculum & with open / sticky
Pit & Fissure.
∂ Stained Pit & Fissure with minimum decalcification /
opacification & no softness at the base of the fissure.
25. 25
CONTRAINDICATIONS
No previous caries experience ,
coalesced Pit & Fissure.
Proximal caries – clinically &
radiographically
Wide & self cleansable Pit & Fissure.
Partially erupted tooth / that which cant be isolated.
Pit & Fissure caries free for > 4 yrs.
26. 26
CASE SELECTION:
AGE RANGE: 3-4 yrs for primary molar, 6-7yrs for 1st
permanent molar, 11-13yrs for 2nd permanent molar.
GROUP 2: Moderate caries risk patients.
CLINICAL JUGDEMENT CRITERIA:
Age
Oral hygiene
Dietary habits
Tooth type & morphology
Familial & individual history of dental caries
Fluoride environment & history
27. 27
1. Preparation of Tooth: An entire quadrant or a single
tooth may be prepared for sealant application.
A careful examination should be used to verify that there is no
decay using careful lighting and illumination after air drying.
The explorer should be used sparingly or with care because a
sharp explorer can damage the fragile outer enamel
morphology.
The tooth is cleaned well (10-15 seconds)
with a prophy brush and a mixture
of flour of pumice and water.
Sealant Application Technique
28. 28
It is important that the pumice mixture contain no oil or
fluoride.
Also, because fluoride renders the outer layer of enamel more
resistant to demineralization or acid etching, fluoride
treatment if indicated should be accomplished after the
sealant is placed, not before.
After the surfaces to be sealed have been cleaned
thoroughly, they are washed well for 10-15 seconds and
dried well for 10-15 seconds.
29. 29
Isolating the teeth because the maintenance of a dry field is
absolutely essential to the success of sealant retention.
Maintaining a dry field of operation for sealant placement may be
accomplished by two basic methods:
(1)the use of the rubber dam
(2) the use of cotton roll holders, cotton rolls and Dri-Angles®.
It is important to emphasize that retention depends heavily on the
maintenance of a dry field during sealant placement.
2. Isolation Techniques: Prior to placing
sealants, careful consideration should be given
30. 30
A. Use of the rubber dam.
B. Use of cotton roll holders, cotton rolls.
The tooth may be kept dry by placing
additional dry
cotton rolls over the wet rolls. It may be
necessary for the operator to use the mirror
or fingers to
retract the tongue and buccal vestibule
while the assistant works with the cotton
rolls.
31. 31
3. Acid Conditioning of the Tooth
This is the most critical step in the sealant application technique
because the retention of the sealant depends on the proper acid
conditioning of the tooth's surface.
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.
Buonocore initially used
80% phosphoric acid but now,
37% phosphoric acid is recommended.
32. 32
It is important to keep the acid agitated gently and replenished during
the acid conditioning period.
Acid conditioning enhances enamel porosity, increases the surface
area and further cleans the enamel surface.
Acid conditioning should be limited
to the tooth surfaces that will be sealed
and care should be taken to keep the
acid away from all soft tissues.
After conditioning, the tooth is rinsed
again with water for 10-15 seconds to
remove the acid and its residues.
33. 33
Then the tooth is dried thoroughly for 10-15 seconds and examined
carefully.
The etched surface should not be
disturbed with further
instrumentation.
If conditioning is adequate and the
etch is good, the tooth will appear
white, opaque and frosty.
If the tooth does not have this appearance, it should be re-etched for
another 30 seconds.
If saliva contact the tooth at any time during etching, the etching
procedure should be repeated from the start.
If saliva should contact the tooth after etching, rerinse and dry the
tooth and re-etch for 30 seconds.
34. 34
Tandon S et al (1989) have proposed an etching time of 15 sec to be
sufficient for primary teeth.
Duggal et al (1997) have used different etching timing of 15, 30, 45,
60 secs and concluded that there is no difference in retention of
sealant using different etching time.
But the most accepted times and the currently applicable times were
given in IADR Sealant Symposium in 1991.
STEP PRIMARY TOOTH PERMANENT
TOOTH
Acid Etch 30 seconds 20 seconds
Wash 30 seconds 30 seconds
Dry 15 seconds 15 seconds
35. 35
4. Sealant Placement
For Autopolymerized Resin
This sealant system requires mixing a catalyst and base to form an
unfilled BIS-GMA resin. One drop of base and one drop of catalyst
are dispensed into the mixing well and mixed together for 15 seconds.
Then, the sealant is carried to the tooth with a customized application
dispenser used for the resin material.
The necessity of a dry operation field is essential because
contamination of the etched enamel with saliva or water will lead to
bond failure. The mixing time is 15 seconds, the working time for
placement is 45 seconds, and the polymerization or setting time starts
in 60 seconds. It is critical that the sealant be applied within 60
seconds; otherwise, the polymerization process will be disturbed and
resin bond to enamel may be compromised. Another 60 seconds are
necessary for complete polymerization. Thus, a total time of 120
seconds is required from start to finish.
36. 36
When using a light-polymerization system, the sealant material is
placed on all susceptible pits and fissures and a few seconds are
allowed for the material to flow into the deep pits and fissures.
The sealant is next cured with the light source according to the
manufacturer's recommendations.
Generally this will be at minimum a 20-second cure time for each
surface that is being sealed.
Light-polymerization System
37. 37
5. Explore the Sealed Tooth Surface and Evaluate Occlusion
Explore the tooth surface for pits and voids that may have not been
sealed.
Evaluate occlusion of sealed tooth surface with articulating paper to
determine if any excessive sealant is present and needs to be removed.
A small discrepancy in occlusion in case of unfilled sealant is easily
tolerated as the cement abrades away but in case of filled resin sealant,
occlusal adjustment is a must to avoid discomfort.
38. 38
6. Sealant Maintenance at Recall Appointment
The sealant should be checked at
subsequent recall appointments
to evaluate its retention.
The effectiveness of pit and fissure
sealants is increased by monitoring
and maintaining the intact sealant.
If the sealant has been lost or only partially retained, more
sealant can be added by repeating the steps in the application
technique already described.
It is not necessary to remove residual sealant before reapplication.
Any sealant material could be used to repair a partially retained
sealant.
39. 39
ADA recommended sequence (1983)
1) Prophylaxis
2) Sealant placement
3) Topical fluoride application
4) Reapplication of sealant every 6 mon
40. 40
CURRENTSTATUS OFPIT&FISSURESEALANTS
Fluoride Releasing Sealants
Garcia Godoy 91997) found out that all
he fluoridated sealants had the greatest
amount of fluoride release by 24 hours
after mixing and themfluoride release
declined sharpely therafter.
Cooley et al (1990) and Hicks et al (1992) conducted lab studies on a
luoride releasing sealant materials composed of a modified urethane
Bis-GMA resin. They also concluded that fluoride release dips
considerably as the days go by. But, they showed that 60% reduction in
econdary caries and enhanced degree of caries resistance was seen.
Eg –
Seal-Rite ( Pulpdent)
Fluoroshield (Dentsply)
Conseal F ( SDI)
41. 41
Clear Pit and Fissure Sealant
This type of sealant is esthetic.
Difficult to detect in recall visits.
Eg –
Helicoseal
( changes from green to white)
42. 42
Colored Pit and Fissure Sealant
The sealant is clear to begin with but after polymerization it changes
its color.
The degree of color change
is also an indicator of its
setting and adequate
polymerization.
Easy to see during placement
and recall.
Eg – Clinpro
( Changes to pink after setting)
43. 43
Fluorescing Pit and Fissure Sealant
This sealant eliminates the guesswork involved with placing sealants
and confirming placement during recall appointments.
Through the use of a 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 and offers
the easiest way to verify retention
and inspect margins during patient
recall appointments.
Eg- Delton Seal-N-Glo (Dentsply)
44. 44
Moist Bonding Pit and Fissure
This is the 1st
pit and fissure sealant resin that can be applied in a
moist field.
When placed in the presence of moisture, the sealant spreads over
the enamel surface.
Because of its unique chemistry,
Embrace Wetbond is miscible with
water and flows into moisture-
containing etched enamel and
combines with it.
It forms unique Resin Acid-Integrating
Network (RAIN) that improves penetration
into pits and fissures and provides superior
sealing of the margins.
45. 45
Advantages includes –
1) Wet bonding.
2) Tooth integrating.
3) No marginal chipping.
4) No need of bonding agent and contains no Bisphenol A;
Bis-GMA or Bis-DMA.
Eg – Embrace Wetbond (Pulpdent Corporation)
46. 46
Pit and Fissure Sealant with ACP
It is a light cured sealant that contains the “Smart Material” Amorphous
Calcium Phosphate (ACP) that is more resilient and flexible, creating
a stronger long lasting sealant.
ACP is referres as smart material
because it only releases calcium and
phosphate ions when the pH drops to 5.9.
Once the calcium phosphate is released,
it will act to neutralize the acid and buffer
the pH. ACP acts as reinforcement to the
tooth’s natural defense system only when it is needed.
It has a controlled flowability that keeps the sealant on the tooth structure
while completely filling occlusal surfaces and it forms a chemical and the
barrier protecting the tooth enamel on the occlusal surface from carious a
Eg – Aegis Pit and Fissure Sealant (Bosworth)
47. 47
Hydrophillic Fluorescent BPA Free Pit and Fissure Sealant
This is a new sealant developed which combines the best properties
of nearly all sealants.
Some of its properties are hydrophillic chemistry, advanced adhesive
technologies, fluorescent properties, thixotrophic velocity, BPR-free
formula.
Thus, not only can it be used in wet environment but also is easy
to place owing to thixotrophic viscosity and is easy to follow up due
to fluorescence.
Eg – UltraSeal XT Hydro.
48. 48
CONCLUSION
The use of fissure sealants as a key primary prevention method is
well documented and it is scientifically proved to have good
results. Dental sealants were introduced to help prevent dental
caries in the pits and fissures, mainly in the occlusal tooth
surfaces. Sealants act to prevent the growth of bacteria that can
lead to dental caries. There is evidence to suggest that fissure
sealants are effective in preventing caries in children and
adolescents when compared to no sealants. Therefore, this
biomaterial should continue to be used to prevent dental caries,
especially among younger people
49. 49
1) Stephen H.Y. Wei, Pediatric Dentistry : Total Patient
Care, Lea & Febiger, 1988; p47-56.
2) Mcdonald and Avery, Dentistry for the Child and
Adolescent, Elsevier Mosby, 9th
Edition; p313-321.
3) Casamassimo, Pediatric Dentistry : Infancy Through
Adolescence, Elsevier, 5th
Edition; p297-299.
4) PR Chockalingam, Illustrated Paediatric Dentistry,
Wolters Kluwer, 1st
Edition; p227-235.
5) Nikhil Marwah, Textbook of Pediatric Dentistry, 3rd
Edition; p285-300.
REFRENCES
