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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      ...
Requirements - continuedPatient requirements  18 years of age or older  Must be in good health  A minimum of four (4) virg...
Certification Requirements Successful completion of written exam Successful completion of laboratory and clinical portions...
Pit and fissure sealants A thin plastic coating placed in the pit and fissures of the teeth to act as a physical barrier t...
Why pit & fissure sealants needed Bacteria produces acid which causes decay “demineralization”
Pit and fissure sealants Over 85% of children (5-17 years old) in US have caries in the pits and fissures Fluoride is leas...
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             4...
Preventive Programs as Related toSealants Tooth brushing and flossing - mechanical plaque removal Fluoride – chemical prev...
Preventive Programs as Related toSealants - continuedDiet Minimize exposure to cariogenic foods and liquids that have litt...
History of Sealants Acrylic polymers introduced to dentistry – 1937 Composites - 1960 “Occlusal Sealing” – 1965 Glass iono...
Retention of Sealants – 4 year studyFluoride releasing   Non-fluoride  sealant             releasing sealant  91% retentio...
Retention of Sealants – 2 year studyFluoride releasing sealant  >90% retention  No caries
Sealant retention
Sealant Failure Debris and/or saliva contamination Air inclusion during manipulation – voids Manipulating self-cured seala...
Loss of Sealant A contaminated site from faulty technique will likely result in complete or partial loss of the sealant wi...
Cost Factors Dental Sealants = $25 - $49 per tooth Amalgam = $75 to $145 per filling Composite = $150 to $200 for a single...
Preventive Resin Restoration The preparation of fissures by use of air abrasion, bur or laser followed by filling the prep...
Incipient Caries Studies have shown that sealants can be placed over incipient caries which arrests the caries process Mos...
Tooth morphology Pits and fissures
Tooth morphology
Tooth morphology
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 se...
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 Ad...
Partially erupted teeth? To seal or not to seal? Operculum (gum flap) – leaks crevicular fluid
Sealant Kits Cavity Indicators Drying and/or bonding agent (optional) Acid etch Sealant material
Acid Etch Gel Liquid 3M Innovation: Adper™ Prompt™ L- Pop™ Self-Etch Adhesive
Acid etch Phosphoric acid 35%-40%-50% Dissolves organic portion of enamel “micromechanical retention”
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 cont...
Acid etch – storage and handlingprotocol Protection – protective eyewear, gloves and clothing Toxicity – mild irritation f...
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...
PrimaDry – storage and handlingprotocol Protection – protective eyewear, gloves and clothing Toxicity – mild irritation fo...
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         ...
Sealant Types                Filled sealants                Unfilled sealants
Accepted Sealant MaterialsADA Council on Scientific Affairs 3M ESPE – Clinpro Sealant Confi-Dental Products Company Dental...
Types of curing for sealantsChemical cured – “autopolymerization” Base and catalystMonomer & Initiator + Diluted monomer &...
Chemical cure sealant materialsAdvantages No cure light or risk of eye damage Can apply sealants to several teethDisadvant...
Light cured sealant materialsAdvantages  Short setting time (appx 20 seconds)  No mixing required  Won’t set-up – longer w...
Sealant Shades Clear Tinted Opaque
Clinpro™ Sealant goeson pink for easy-to-seeapplication, and cures toa natural white.low viscosity, fluoride-releasing sea...
Sealant Material – precautions Active ingredient – Bis-GMA Skin contact – wash with soap and water Eye contact – flush wit...
Sealant Material – storage andhandling protocol Protection – protective eyewear, gloves and clothing Toxicity – mild irrit...
Concepts of bonding Mechanical bonding – interlocking Chemical bonding – use of adhesive Physical bonding – attraction of ...
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 fissu...
Curing units Conventional cure light with halogen bulb = 20 seconds cure for each surface Plasma arc or laser = 5-10 seconds
Assemble armamentarium
Assemble sealant kit Check the operation of the syringe on gauze
Armamentarium
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  plast...
Give patient instructions                Verbal instructions                  This won’t hurt but                  you wil...
Wear personal protectiveequipment - operator Gloves Mask Safety glasses/visor Protective clothing Closed toed shoes
Wear personal protectiveequipment - patient Safety glasses Pt. glasses should be tinted when using a curing light (operato...
Position patient   Mandibular      Maxillary
Check prescription and teeth Occlusal surfaces Buccal and lingual pits on first molars Lingual pits on upper anterior teeth
Suspicious lesions? Explorer – “a stick” Caries indicator dye DIAGNOdent
Prepare the tooth Bristle brush or rubber cup and plain pumice Dentist can use bur, air abrasion or laser Sharp explorer t...
Prepare the Tooth - continued air abrasion, bur, prophy jet or laser
Position the patient
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 r...
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 minerali...
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 ...
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...
Light cure for 20 seconds  20 seconds each tooth  Don’t touch tip of cure  light to sealant  material  Don’t let saliva  c...
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...
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-shape...
Give patient instructions The sealant is hard so you don’t have any restrictions on eating If it feels “high” after you go...
Documentation9/1/05 Medical history updated – no changes.  Parent consented to sealants on #19 OB and  #30 OB. Cotton roll...
Infection control Disinfect unit Disinfect sealant syringes Throw away brush tips used in patient’s mouth Sharp tips need ...
Common ProblemsRe-etch Improperly etched surface – doesn’t appear frosty and chalky white Dentin etching – need to dissolv...
Failure of sealants Main cause – moisture contamination Maxillary and mandibular 2nd molars Early loss means less retentio...
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 che...
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 seal...
Finished!
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Pit & fissure sealants (1)

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Pit & fissure sealants (1)

  1. 1. Pit and Fissure SealantsCara Miyasaki-Ching, RDHEF, MS
  2. 2. Legal requirements RDA, RDAEF – DDS decision or supervision RDH, DDS/DMD – General supervision Sealant adjustments
  3. 3. 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
  4. 4. 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
  5. 5. Certification Requirements Successful completion of written exam Successful completion of laboratory and clinical portions of the course
  6. 6. 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
  7. 7. Why pit & fissure sealants needed Bacteria produces acid which causes decay “demineralization”
  8. 8. 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
  9. 9. Effectiveness of sealants 15 year study – 68% of sealed teeth were caries free vs 17% of unsealed control group
  10. 10. 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%
  11. 11. Preventive Programs as Related toSealants Tooth brushing and flossing - mechanical plaque removal Fluoride – chemical prevention Dental visits – mechanical plaque removal and chemical prevention
  12. 12. 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
  13. 13. History of Sealants Acrylic polymers introduced to dentistry – 1937 Composites - 1960 “Occlusal Sealing” – 1965 Glass ionomers – 1972
  14. 14. Retention of Sealants – 4 year studyFluoride releasing Non-fluoride sealant releasing sealant 91% retention 95% retention (77% complete (89% complete & & 14% partial) 6% partial) 10% caries rate 10% caries rate
  15. 15. Retention of Sealants – 2 year studyFluoride releasing sealant >90% retention No caries
  16. 16. Sealant retention
  17. 17. Sealant Failure Debris and/or saliva contamination Air inclusion during manipulation – voids Manipulating self-cured sealants late in the setting reaction
  18. 18. Loss of Sealant A contaminated site from faulty technique will likely result in complete or partial loss of the sealant within 6-12 months.
  19. 19. 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
  20. 20. Preventive Resin Restoration The preparation of fissures by use of air abrasion, bur or laser followed by filling the prep with a flowable composite.
  21. 21. 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
  22. 22. Tooth morphology Pits and fissures
  23. 23. Tooth morphology
  24. 24. Tooth morphology
  25. 25. Tooth morphology Why fissures are caries susceptible
  26. 26. Selection of teethConsiderations Patient age Oral hygiene Caries risk Diet Fluoride history Tooth type Morphology
  27. 27. 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
  28. 28. Indications Deep fissures Incomplete or ill formed pits Newly erupted teeth High caries rate Children Molars
  29. 29. Contraindications Shallow fissures Well coalesced pits Fluoride rich enamel Low caries rate Occlusal or proximal caries Adults
  30. 30. Partially erupted teeth? To seal or not to seal? Operculum (gum flap) – leaks crevicular fluid
  31. 31. Sealant Kits Cavity Indicators Drying and/or bonding agent (optional) Acid etch Sealant material
  32. 32. Acid Etch Gel Liquid 3M Innovation: Adper™ Prompt™ L- Pop™ Self-Etch Adhesive
  33. 33. Acid etch Phosphoric acid 35%-40%-50% Dissolves organic portion of enamel “micromechanical retention”
  34. 34. Acid etch - continued Creates more surface area for better adhesion Also high energy surface
  35. 35. Acid etch - Precautions Avoid contact with adjacent teeth or soft tissues Can use mylar strips or matrix bands
  36. 36. 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.
  37. 37. 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.
  38. 38. Acid etch - continuedWill an etched tooth be more prone to decay? Remineralization begins after 24 hours
  39. 39. Drying agent (PrimaDry) Acid etching and Primadry (alcohol based) allows enamel to be easily “wetted”
  40. 40. 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.
  41. 41. 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.
  42. 42. Sealant composition A type of specialized plastic (resin) or glass ionomer material Matrix Filler
  43. 43. 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
  44. 44. Sealant Types Filled sealants Unfilled sealants
  45. 45. 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
  46. 46. 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
  47. 47. 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
  48. 48. 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
  49. 49. Sealant Shades Clear Tinted Opaque
  50. 50. Clinpro™ Sealant goeson pink for easy-to-seeapplication, and cures toa natural white.low viscosity, fluoride-releasing sealant
  51. 51. 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
  52. 52. 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.
  53. 53. Concepts of bonding Mechanical bonding – interlocking Chemical bonding – use of adhesive Physical bonding – attraction of atomic charges
  54. 54. Requirements for Adhesion Clean surface Good wetting by adhesive Good adaptation to the substrate Good interface Good curing
  55. 55. 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
  56. 56. Curing units Conventional cure light with halogen bulb = 20 seconds cure for each surface Plasma arc or laser = 5-10 seconds
  57. 57. Assemble armamentarium
  58. 58. Assemble sealant kit Check the operation of the syringe on gauze
  59. 59. Armamentarium
  60. 60. Curing units CAUTION – Avoid looking directly at the light
  61. 61. 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
  62. 62. 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.
  63. 63. Wear personal protectiveequipment - operator Gloves Mask Safety glasses/visor Protective clothing Closed toed shoes
  64. 64. Wear personal protectiveequipment - patient Safety glasses Pt. glasses should be tinted when using a curing light (operator/assistant should have tinted glasses on shields)
  65. 65. Position patient Mandibular Maxillary
  66. 66. Check prescription and teeth Occlusal surfaces Buccal and lingual pits on first molars Lingual pits on upper anterior teeth
  67. 67. Suspicious lesions? Explorer – “a stick” Caries indicator dye DIAGNOdent
  68. 68. Prepare the tooth Bristle brush or rubber cup and plain pumice Dentist can use bur, air abrasion or laser Sharp explorer to clean out debris Rinse
  69. 69. Prepare the Tooth - continued air abrasion, bur, prophy jet or laser
  70. 70. Position the patient
  71. 71. Check occlusion Avoid placing acid etch and sealant on marked areas from articulator paper
  72. 72. Isolate tooth/teethTreat quadrants separately To control isolation To prevent contamination by moisture
  73. 73. Isolate tooth/teeth Rubber dam Cotton rolls Cotton roll holders Dri-angle
  74. 74. Dry toothTest air/water syringe before applying blast of air
  75. 75. 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
  76. 76. Apply acid etch - continued 3M Innovation: Adper™ Prompt™ L- Pop™ Self-Etch Adhesive Etch, prime and bond
  77. 77. Apply acid etch Etch pit and fissures Extend 1-2 mm beyond pit and fissures Avoid cusp tips
  78. 78. Acid etch - continuedEtch longer Deciduous teeth Saliva contamination Air abrasion or prophy jet used Highly mineralized teethDo not use explorer
  79. 79. Rinse tooth/teeth Use HVE and a/w syringe Proper – usually 20 seconds rinse Avoid saliva contamination Re-isolate
  80. 80. Dry tooth/teeth Should appear chalky or frosty white if etched If not, re-etch for another 10 seconds if not contaminated with saliva
  81. 81. Apply drying agent (PrimaDry) Use brush tip Apply and leave for 5 seconds Gently blow air to dry DON’T RINSE
  82. 82. Apply bond agent A bond agent will improve retention
  83. 83. 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
  84. 84. 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
  85. 85. Light cure for 20 seconds – airinhibition theory Top layer of sealant will remain uncured sealant will appear shiny/wet
  86. 86. Check sealed teeth Use explorer Tooth should be smooth but not soft Re-apply sealant, if necessary (Remove uncured sealant with wet cotton roll)
  87. 87. Remove isolation materials Moisten Dri-angle Rinse the patient’s mouth
  88. 88. Check occlusion & contact(s) Articulating paper Dental floss Ask patient how it feels Dentist can adjust with bullet-shaped finishing bur or polishing stone
  89. 89. 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)
  90. 90. 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.
  91. 91. 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
  92. 92. 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
  93. 93. Failure of sealants Main cause – moisture contamination Maxillary and mandibular 2nd molars Early loss means less retention of the resin
  94. 94. Sealing over caries For incipient caries – risk of progression is very small
  95. 95. 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
  96. 96. Sealant maintenance Loss of all or part of the sealant Staining at edges Discoloration underneath sealant
  97. 97. Repair of sealantReapply if totally lostRepair partial loss Roughen with diamond stone Re-etch 20 seconds Reapply sealant
  98. 98. Finished!

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