Over 85% of children (5-17 years old) in US have caries in the pits and fissures - these children are mostly from low-income families and other vulnerable populations
Initial studies of community water fluoridation demonstrated that reductions in childhood dental caries attributable to fluoridation were approximately 50%--60% ( 94--97 ). More recent estimates are lower --- 18%--40% ( 98,99 ). This decrease in attributable benefit is likely caused by the increasing use of fluoride from other sources, with the widespread use of fluoride toothpaste probably the most important. The diffusion or "halo" effect of beverages and food processed in fluoridated areas but consumed in nonfluoridated areas also indirectly spreads some benefit of fluoridated water to nonfluoridated communities. This effect lessens the differences in caries experience among communities ( 100 ). Studies of the effects of school water fluoridation in the United States reported that this practice reduced caries among schoolchildren by approximately 40% ( 118--122 ). A more recent study indicated that this effect might no longer be as pronounced ( 123 ). Studies of 2--3 years duration have reported that fluoride toothpaste reduces caries experience among children by a median of 15%--30% ( 139--148 ). This reduction is modest compared with the effect of water fluoridation, but water fluoridation studies usually measured lifetime --- rather than a few years' --- exposure. Regular lifetime use of fluoride toothpaste likely provides ongoing benefits that might approach those of fluoridated water. Combined use of fluoride toothpaste and fluoridated water offers protection above either used alone ( 99,149,150 ). Studies indicating that fluoride mouthrinse reduces caries experience among schoolchildren date mostly from the 1970s and early 1980s ( 184--191 ). In one review, the average caries reduction in nonfluoridated communities attributable to fluoride mouthrinse was 31% ( 191 ). Two studies reported benefits of fluoride mouthrinse approximately 2.5 and 7 years after completion of school-based mouthrinsing programs ( 192,193 ), but a more recent study did not find such benefits 4 years after completion of a mouthrinsing program ( 194 ). The National Preventive Dentistry Demonstration Program (NPDDP), a large project conducted in 10 U.S. cities during 1976--1981 to compare the cost and effectiveness of combinations of caries-prevention procedures, reported that fluoride mouthrinse had little effect among schoolchildren, either among first-grade students with high and low caries experience ( 195 ) or among all second- and fifth-grade students ( 196 ). NPDDP documented only a limited reduction in dental caries attributable to fluoride mouthrinse, especially when children were also exposed to fluoridated water. The evidence for using fluoride supplements to mitigate dental caries is mixed. Use of fluoride supplements by pregnant women does not benefit their offspring ( 198 ). Several studies have reported that fluoride supplements taken by infants and children before their teeth erupt reduce the prevalence and severity of caries in teeth ( 98,199--207 ), but several other studies have not ( 19,208--212 ). Among children aged 6--16 years, fluoride supplements taken after teeth erupt reduce caries experience ( 213--215 ). Fluoride supplements might be beneficial among adults who have limitations with toothbrushing, but this use requires further study. Clinical trials conducted during 1940--1970 demonstrated that professionally applied fluorides effectively reduce caries experience in children ( 233 ). In more recent studies, semiannual treatments reportedly caused an average decrease of 26% in caries experience in the permanent teeth of children residing in nonfluoridated areas ( 191,234--236 ). The application time for the treatments was 4 minutes. In clinical practice, applying fluoride gel for 1 minute rather than 4 minutes is common, but the efficacy of this shorter application time has not been tested in human clinical trials. In addition, the optimal schedule for repeated application of fluoride gel has not been adequately studied to support definitive guidelines, and studies that have examined the efficacy of various gel application schedules in preventing and controlling dental caries have reported mixed results. On the basis of the available evidence, the usual recommended frequency is semiannual ( 151,237,238 ). Studies conducted in Canada ( 242 ) and Europe ( 243--246 ) have reported that fluoride varnish is efficacious in preventing dental caries in children. Applied semiannually, this modality is as effective as professionally applied fluoride gel ( 247 ). Some researchers advocate application of fluoride varnish as many as four times per year to achieve maximum effect, but the evidence of benefits from more than two applications per year remains inconclusive ( 240,246,248 ). Other studies have reported that three applications in 1 week, once per year, might be more effective than the more conventional semiannual regimen ( 249,250 ). Combinations of Fluoride Modalities Studies comparing various combinations of fluoride modalities have generally reported that their effectiveness in preventing dental caries is partially additive. That is, the percent reduction in the prevalence or severity of dental caries from a combination of modalities is higher than the percent reduction from each modality, but less than the sum of the percent reduction of the modalities combined. Attempts to use a formula to apply sequentially the percent reduction of an additional modality to the estimated remaining caries increment have overestimated the effect ( 151,253 ). For example, if the first modality reduces caries by 40% and the second modality reduces caries by 30%, then the calculation that caries will be reduced by a total of 58% (i.e., 40% plus 18% [30% of the 60% decay remaining after the first modality]) will likely be an overestimate.
Liquids – soft drinks, fruit drinks, cocoa, sugar and honey in beverages, nondairy creamers, ice cream, sherbet, jello, flavored yogurt, pudding, custard, popsicles. Solid and Sticky – cake, cupcakes, donuts, sweet rolls, pastry, canned fruit in syrup, bananas, cookies, chocolate candy, caramel, toffee, jelly beans, other chewy candy, chewing gum, dried fruit, marshmallows, jelly, jam Slowly Dissolving – hard candies, breath mints, antacid tablets, cough drops
“ Occlusal Sealing” – 1965 Mixing methyl-2-cyanoacrylate with poly(methyl methacrylate) and inorganic powder then placed in pits and fissures. Polymerized on exposure to moisture
Debris and/or saliva contamination – use a hydrophilic primer to dry the tooth surface and thoroughly clean the tooth Air inclusion during manipulation – surface voids which can discolor and retain plaque Manipulating self-cured sealants late in the setting reaction can disrupt polymerization and induce bond failure
(Bis-GMA) Bisphenol A-glycidyl methacrylate resins 3 parts composite resin mixed with a diluent (methyl methacrylate or triethylene glycol dimethacrylate) – to obtain a low-viscosity sealant Sealants with fluoride – Glass ionomer Anticariogenic- high fluoride content Since viscous it is difficult to gain penetration to the depth of the fissure. This lack of penetration makes it difficult to obtain mechanical retention to the enamel surface to the same degree as Bis-GMA resins
Filler makes sealant more wear resistant and more visible upon clinical inspection Filler – fumed silica or silanated inorganic glasses Unfilled sealants are clear making detection difficult. Less resistant to wear over the long term. Best used when high spots can’t be adjusted i.e. school based setting.
The surface of the substrate be clean The adhesive wet the substrate well, have a low contact angle, and spread onto the surface Adaptation to the substrate produce intimate approximation of the materials without entrapped air or other intervening materials The interface include the sufficient physical, chemical, and/or mechanical strength to resist intraoral forces of debonding The adhesive be well cured under the conditions recommended for use.
Avoid rubbing the etched surface during etching and drying because the roughness developed can easily be destraoyed. The etched area should extend beyond the anticipated area for sealant application to secure optimum bonding along the margin aad reduce the potential for early leakage.
Inadequate rinsing permits phosphate salts to remain on the surface as a contaminant, interfering with bond formation
Bond agent will improve retention especially when there appears to be minor moisture or salivary contamination.
Pit & fissure sealants (1)
Pit and Fissure SealantsCara Miyasaki-Ching, RDHEF, MS
Legal requirements RDA, RDAEF – DDS decision or supervision RDH, DDS/DMD – General supervision Sealant adjustments
Requirements - minimum16 clock hours total Student shall: 4 hours of didactic Have current CPR training Take a written exam 4 hours of laboratory RDA or RDA eligible training (this includes coronal 8 hours of clinical polish) training
Requirements - continuedPatient requirements 18 years of age or older Must be in good health A minimum of four (4) virgin, non-restored, natural teeth, sufficiently erupted so that a dry field can be maintained. A minimum of one tooth per quadrant
Certification Requirements Successful completion of written exam Successful completion of laboratory and clinical portions of the course
Pit and fissure sealants A thin plastic coating placed in the pit and fissures of the teeth to act as a physical barrier to decay
Pit and fissure sealants Over 85% of children (5-17 years old) in US have caries in the pits and fissures Fluoride is least effective on pit and fissures Only 18% of school-aged children in US have sealants
Effectiveness of sealants 15 year study – 68% of sealed teeth were caries free vs 17% of unsealed control group
Other Preventive Programs Community water fluoridation 50-60% (18-40%) School water fluoridation 40% Fluoridated toothpaste 15-30% Fluoride mouthrinse 31% In-office treatment 26%
Preventive Programs as Related toSealants Tooth brushing and flossing - mechanical plaque removal Fluoride – chemical prevention Dental visits – mechanical plaque removal and chemical prevention
Preventive Programs as Related toSealants - continuedDiet Minimize exposure to cariogenic foods and liquids that have little or no nutritional value Minimize solid and sticky foods Minimize slowly dissolving foods
History of Sealants Acrylic polymers introduced to dentistry – 1937 Composites - 1960 “Occlusal Sealing” – 1965 Glass ionomers – 1972
Sealant Failure Debris and/or saliva contamination Air inclusion during manipulation – voids Manipulating self-cured sealants late in the setting reaction
Loss of Sealant A contaminated site from faulty technique will likely result in complete or partial loss of the sealant within 6-12 months.
Cost Factors Dental Sealants = $25 - $49 per tooth Amalgam = $75 to $145 per filling Composite = $150 to $200 for a single surface white composite filling Medical reimbursement Insurance reimbursement
Preventive Resin Restoration The preparation of fissures by use of air abrasion, bur or laser followed by filling the prep with a flowable composite.
Incipient Caries Studies have shown that sealants can be placed over incipient caries which arrests the caries process Most dentists choose to use air abrasion, a bur, or a laser to remove the caries before the sealant is placed
Tooth morphology Why fissures are caries susceptible
Selection of teethConsiderations Patient age Oral hygiene Caries risk Diet Fluoride history Tooth type Morphology
Selection of teeth - continued Frequency of pit & fissure caries Lower molars – 50% Upper molars 35-40% Upper and lower second premolars Upper laterals and upper first premolars Upper centrals and lower first premolars
Indications Deep fissures Incomplete or ill formed pits Newly erupted teeth High caries rate Children Molars
Contraindications Shallow fissures Well coalesced pits Fluoride rich enamel Low caries rate Occlusal or proximal caries Adults
Partially erupted teeth? To seal or not to seal? Operculum (gum flap) – leaks crevicular fluid
Acid etch - continued Creates more surface area for better adhesion Also high energy surface
Acid etch - Precautions Avoid contact with adjacent teeth or soft tissues Can use mylar strips or matrix bands
Acid etch –Precautions cont. Active ingredient – phosphoric acid Avoid contact with skin, eyes, and clothing. If skin contact – flush with water If eye contact – flush immediately with water and seek medical attention If ingestion- do not induce vomiting. Give large amounts of water or milk. Take an antacid. Call a physician.
Acid etch – storage and handlingprotocol Protection – protective eyewear, gloves and clothing Toxicity – mild irritation for skin or ingestion but damage to eye exposure if chronic exposure. Storage - Store at room temperature. Handling – Use gloves, protective eyewear and PPE.
Acid etch - continuedWill an etched tooth be more prone to decay? Remineralization begins after 24 hours
Drying agent (PrimaDry) Acid etching and Primadry (alcohol based) allows enamel to be easily “wetted”
PrimaDry – precautions Active ingredient – ethyl alcohol If skin contact – wash with soap and water If eye contact – flush with lots of water Ingestion- give large amounts of water or milk.
PrimaDry – storage and handlingprotocol Protection – protective eyewear, gloves and clothing Toxicity – mild irritation for skin or ingestion but severe irritation for eye exposure Storage - Store at room temperature. Keep out of heat and/or direct sunlight. Handling – Use gloves and protective eyewear.
Sealant composition A type of specialized plastic (resin) or glass ionomer material Matrix Filler
Sealant TypesResin Sealants Glass Ionomer Sealants (Bis-GMA) Bisphenol Anticariogenic A-glycidyl More viscous, less methacrylate resins retention, more brittle Urethane-based resin and less resistant to occlusal wear
Accepted Sealant MaterialsADA Council on Scientific Affairs 3M ESPE – Clinpro Sealant Confi-Dental Products Company Dental Technologies Dentsply International - FluroShield Ivoclar Vivadent, Inc. - Helioseal Kuraray America Inc. – Teethmate F-1 PracticeWares Dental Supply Pulpdent Corporation Southern Dental Industries Tru-Tain Prime Dental Ultradent Products, Inc. - Ultraseal Zenith/DMG Dental Manufacturing
Types of curing for sealantsChemical cured – “autopolymerization” Base and catalystMonomer & Initiator + Diluted monomer & 5% Organic Amine Accelerator = SealantVisible light cured – “photopolymerization” Pre-mixed Dimethacrylate + Diluent + Activator + Light = Sealant
Chemical cure sealant materialsAdvantages No cure light or risk of eye damage Can apply sealants to several teethDisadvantages Variation in setting time (appx 2 min) Voids from mixing material Changes in viscosity over time
Light cured sealant materialsAdvantages Short setting time (appx 20 seconds) No mixing required Won’t set-up – longer working time Does not get thickDisadvantages Potential eye damage due to light cure Additional cost of cure light Cure time increased with number of teeth sealed Difficult to manipulate cure light for posterior teeth
Clinpro™ Sealant goeson pink for easy-to-seeapplication, and cures toa natural white.low viscosity, fluoride-releasing sealant
Sealant Material – precautions Active ingredient – Bis-GMA Skin contact – wash with soap and water Eye contact – flush with lots of water & call physician if needed Ingestion- in large amounts induce vomiting
Sealant Material – storage andhandling protocol Protection – protective eyewear, gloves and clothing Toxicity – mild irritation for skin and eye. Low possiblility of sensitization upon prolonged exposure for the skin. Storage - Refrigerate when not in use. Handling – Use gloves, protective eyewear and PPE.
Concepts of bonding Mechanical bonding – interlocking Chemical bonding – use of adhesive Physical bonding – attraction of atomic charges
Requirements for Adhesion Clean surface Good wetting by adhesive Good adaptation to the substrate Good interface Good curing
Strength and Viscosity CharacteristicsViscosity The thicker the sealant the less likely to penetrate to depth of fissureWear of Sealants Considerations for wear – less filler, more wear and visa versa
Curing units Conventional cure light with halogen bulb = 20 seconds cure for each surface Plasma arc or laser = 5-10 seconds
Curing units CAUTION – Avoid looking directly at the light
Give patient instructionsVerbal instructions I will be placing a dental sealant on your teeth – it’s like a thin plastic coating on top of the tooth and will help prevent cavities If you have any problems then raise your left hand
Give patient instructions Verbal instructions This won’t hurt but you will need to keep open for a long time and it doesn’t taste very good.
Check occlusion Avoid placing acid etch and sealant on marked areas from articulator paper
Isolate tooth/teethTreat quadrants separately To control isolation To prevent contamination by moisture
Isolate tooth/teeth Rubber dam Cotton rolls Cotton roll holders Dri-angle
Dry toothTest air/water syringe before applying blast of air
Apply acid etch 15-20 seconds Use blue micro tip or brush tip Apply only in pit and fissures For liquid – dab but do not rub Re-etch 10 seconds if saliva contamination
Apply acid etch - continued 3M Innovation: Adper™ Prompt™ L- Pop™ Self-Etch Adhesive Etch, prime and bond
Apply acid etch Etch pit and fissures Extend 1-2 mm beyond pit and fissures Avoid cusp tips
Acid etch - continuedEtch longer Deciduous teeth Saliva contamination Air abrasion or prophy jet used Highly mineralized teethDo not use explorer
Rinse tooth/teeth Use HVE and a/w syringe Proper – usually 20 seconds rinse Avoid saliva contamination Re-isolate
Dry tooth/teeth Should appear chalky or frosty white if etched If not, re-etch for another 10 seconds if not contaminated with saliva
Apply drying agent (PrimaDry) Use brush tip Apply and leave for 5 seconds Gently blow air to dry DON’T RINSE
Apply bond agent A bond agent will improve retention
Apply sealant material Most posterior tooth first Extend 1-2 mm beyond pit and fissures Gently work into pits and fissures Avoid lifting off tooth Don’t overfill “pop” bubbles in sealant with explorer or brush tip before curing
Light cure for 20 seconds 20 seconds each tooth Don’t touch tip of cure light to sealant material Don’t let saliva contaminate the field…..yetNote: sealant will appear shiny/wet
Light cure for 20 seconds – airinhibition theory Top layer of sealant will remain uncured sealant will appear shiny/wet
Check sealed teeth Use explorer Tooth should be smooth but not soft Re-apply sealant, if necessary (Remove uncured sealant with wet cotton roll)
Remove isolation materials Moisten Dri-angle Rinse the patient’s mouth
Check occlusion & contact(s) Articulating paper Dental floss Ask patient how it feels Dentist can adjust with bullet-shaped finishing bur or polishing stone
Give patient instructions The sealant is hard so you don’t have any restrictions on eating If it feels “high” after you go home – you can come in to get it adjusted We will keep checking the sealant at subsequent appointments (if using unfilled corposite sealant the bite will self adjust in 2-3 days)
Documentation9/1/05 Medical history updated – no changes. Parent consented to sealants on #19 OB and #30 OB. Cotton rolls and dri-angle isolation. Ultraseal etch, primer and light cured sealant used. Patient tolerated procedure well. Informed parent that sealant will be checked at recall appointments.
Infection control Disinfect unit Disinfect sealant syringes Throw away brush tips used in patient’s mouth Sharp tips need to be placed with sharps container
Common ProblemsRe-etch Improperly etched surface – doesn’t appear frosty and chalky white Dentin etching – need to dissolve smear layer Contamination of application site – saliva Non-adherence of sealant material
Failure of sealants Main cause – moisture contamination Maxillary and mandibular 2nd molars Early loss means less retention of the resin
Sealing over caries For incipient caries – risk of progression is very small
Risks associated with sealants No carcinogens or toxic materials Have xenoestrogens – concentrations too low Potential chemical burns from phosphoric acid Occlusal trauma Danger from cure light
Sealant maintenance Loss of all or part of the sealant Staining at edges Discoloration underneath sealant
Repair of sealantReapply if totally lostRepair partial loss Roughen with diamond stone Re-etch 20 seconds Reapply sealant