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; 8th 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
A. 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*
1. Glass ionomer cement sealants
2. sealants with bonding agents
3. Self-etching light cured sealants
4. Fluoride releasing sealants
5. Moisture-resistant sealants
6. Colored versus clear sealants
13
* Ref: Norman O.Harris. Primary preventive dentistry, 2014; 8th 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 active
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.
1. Ages 3 and 4 years are the most important times for sealing the
eligible deciduous teeth.
2. Ages 6-7 years for the first permanent molars.
3. 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:
1. Deciduous teeth have less mineral and more organic material in the
enamel.
2. Deciduous teeth have a larger internal pore volume and thus more
exogenous organic material.
20

21. 3. Deciduous teeth have more prism less enamel on their surface than
do permanent teeth.
4. 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
1. Gwinnet AJ. The ultrastructure of the ‘prismless’ enamel of permanent human
teeth. Arch Oral Biol,1967;12: 381—8.
2. Gwinnett AJ. Human prismless enamel and its influence on sealant penetration.
Arch Oral Biol,1973;18:441-444.
3. Kodaka T, Kuroiwa H, Higashi S. Structural and distribution patterns of surface
prismless enamel in human permanent teeth. Caries Research, 1991;25:7—20.
4. 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.
5. 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.
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.

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

29. 29

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

32. 32

33. 33

34. 34

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. 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
1. U.V light cure (320-395nm)
2. LED CURING LIGHT (440-490nm)
3. Tungsten halogen curing light (400-500nm)
4. Plasma Arc (400-500nm)
5. 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
1. Gwinnet AJ. The ultrastructure of the ‘prismless’ enamel of permanent human teeth. Arch
Oral Biol,1967;12: 381—8.
2. Gwinnett AJ. Human prismless enamel and its influence on sealant penetration. Arch Oral
Biol,1973;18:441-444.
3. 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.
4. 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.
5. Kodaka T, Kuroiwa H, Higashi S. Structural and distribution patterns of surface prismless
enamel in human permanent teeth. Caries Research, 1991;25:7—20.
6. WF Waggoner and M Siegal. Pit and fissure sealant application: An updating technique. J
Am Dent Assoc, 1996; 127: 351-361.
7. 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
8. 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.
9. 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.
10. 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).
11. 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
12. Harshpriya et al, Recent trends in preventive dentistry-A review; SRM University
dental journal, 2011;2(3):232-237.
13. 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
14. Norman O.Harris. Primary preventive dentistry, 2014; 8th edition; pearson publisher,
pg:273-283.
15. George Babu et al Pit and fissure sealants in pediatric dentistry. SRM Journal of
Research in Dental Sciences,2014; 5(4):253-257.
16. 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.
17. 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
18. 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.