Sealants & preventive resin restorations / dental courses

SEALANTS AND
PREVENTIVE
RESIN
RESTORATIONS
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

CONTENTS
 INTRODUCTION
 PREVALENCE OF OCCLUSAL CARIES IN CHILDREN
 HISTORY
 INEFFECTIVENESS OF FLUORIDE
 EFFECTIVENESS OF SEALANTS
 BONDING PHENOMENON

 CLINICAL PROBLEMS
 OCCLUSAL SEALANT TECHNIQUE
 PREVENTIVE RESIN RESTORATIONS
 CONCLUSION

INTRODUCTION

PREVALENCE OF OCCLUSAL
CARIES IN CHILDREN

 National dental caries survey conducted in the
U.S. from 1979 – 1980 ---- 84% caries experience
for 5-17 yr olds involving pit and fissures.
 Swango and Brunelle (1983) --- prevalence of
occlusal caries in permanent first molar 20% by
age 8 and 70% by age 17.

 High prevalence and rapid onset of occlusal
caries is related to the
i) bacterial and nutrient harboring capacity of pit
and fissures.
ii) close proximity of its base to the DEJ.
iii) total inaccessibility of this area to any
mechanical means of debridement.

 Berman and Slack (1973)---- takes app 3yr for
occlusal caries to reach its peak incidence in
newly erupted molars.

Historic development of preventive
techniques for the occlusal surface

 Taylor and Gwinnet (1973)---- debris remained in
fissure sites regardless of the means of
prophylaxis.
 Hyatt (1923) --- Prophylactic odontotomy.
 Development of topical and systemic fluorides –
in 1950.
 Buonocore (1955) --- adhering resin to an acid
etched enamel surface.

 Buonocore and Cueto (1967)--- first clinical trial
reported using Cyanoacrylate.
 Later (1971) Bis-GMA ultraviolet light – activated
resin was substitued.
 Recent development of either auto polymerization
or visible light polymerization --- have evolved the
technique to its current status

INEFFECTIVENESS OF FLUORIDE
 Backer and Dirks (1974) --- after 15 yr of
systemic fluoride ingestion in Tiel, Holland.

Prevalence of caries in non-fluoridated
community compared with fluoridated
community
Types of caries Culemborg Tiel Difference Reduction
Pit and fissure caries
12.9 8.2 4.7 36%
Smooth proximal caries
10.1 2.5 7.6 75%
Smooth gingival caries
3.6 0.5 3.1 86%
Total caries 26.6 11.2 15.4 58%
Mean no. of carious surfaces per child

 When permanent 1st
molars were analyzed 3yr
after eruption --- caries prevalence for pit and
fissures were greater for non – fluoridated area
than for fluoridated areas.

 Recent survey--- by the National preventive
dentistry demonstration program --- no difference
in the occlusal caries from fluoridated and non-
fluoridated communities.
 The ingestion of systemic fluoride during pre
eruptive development of tooth --- reduced caries
susceptibility of its occlusal surface.

 In conclusion, even with optimal fluoride therapy,
pit and fissure caries may be delayed but not
prevented , on the same scale as smooth surface
lesion.

EFFECTIVENESS OF SEALANTS
 Occlusal sealants are defined as the application
and mechanical bonding of a resin material to
an acid etched enamel surface, there by sealing
existing pits and fissures from the oral
environment.

 Effectiveness of single application of sealant
 Ripa (1985) ---- mean percent retention and
caries reduction of singularly applied sealants
to permanent teeth.

Mean retention and caries reduction
from a single application of sealant
Duration(y) Sealant
retention(%)
Caries
reduction (%)
1 80 82
2 71 68
3 58 65
4 51 43
5 43 36
6 54 40
7 49 34www.indiandentalacademy.com

THE RECOMMENDED SEQUENCE OF
TREATMENT IS (ADA , 1987)
 prophylaxis first
 sealant placement
 topical fluoride application
 repeated every 6 months if needed.

 Bagramian et al (1979) ---- effectiveness of
sealants when the recommended regimen is
used
 The results showed that caries reduction ---
87.5% over 3 yr period and mean no of
reapplication per tooth ---1.8 times .

 Council of dental materials and devices stated
---- pit and fissure sealants, properly applied ,
form an acceptable part of proven effective
preventive measure.
 Time and cost effectiveness of sealants

 Leake and martinello et al (1976) --- initial
placement of sealant to prevent occlusal caries
is reported to cost more than amalgam
restoration.
 The caries reduction of 22 – 24 % is less than 41
– 43 %

 Leverett et al (1983) --- 4 yr period --- five
sealants have to place and maintained to
prevent one carious lesion from developing in a
sound tooth
 Simonson (1989)--- single application and one
reapplication, --- 2/3 the cost of treating the
caries .

 Dennison et al (1980) compared sealant
placement and amalgam restoration as
alternative treatments in terms of cost
effectiveness.
 The results --- re treatment rate for sealants –
17.3% after 6 months and declined to 7.8% after
18 months.

 Marginal deterioration is >50% in Ag
restoration, 55% sealant margins remained.
 After 7 yrs , 50% --- maintained without
reapplication, 30% received reapplication, 10%
-- 2 reapplication, 10% -- 3 reapplication.
 Time effectiveness --- not to be a major concern.

 Ripa (1985) --- cost of placement can be
minimized by
i) delegating treatment to auxiliary personnel
where legally permitted
ii) selecting commercial products that have the
highest proved success rates
iii) following meticulous application protocol
iv) applying sealants in conjunction with optimal
fluoride therapy.

RETENTIVE CHARACTERISTICS OF
ETCHED ENAMEL : THE BONDING
PHENOMENON.

 Normal enamel is composed of hydroxyapatite
crystals arranged in hexagonal prisms forming
rods oriented at right angles to the surface.

 The enamel surface --- low energy, weakly
reactive, hydrophobic state.
 When exposed to acid --- high energy, strongly
reactive, hydrophilic state.
 The acid also etches the enamel surface
producing increased surface area and porosity.

 Silverstone (1975) --- Three different surface
patterns
 Type 1 – preferential removal of the prism core.
 Type 2 – preferential removal of the prism
periphery.
 Type 3 – Random pattern of both types.

 Research has investigated the effect of various
acid conc. on enamel etching --- inverse
relationship between acid conc. and changes in
surface topography.
 The most effective acid conc. appears to be
between 30% - 40%.
 Silverstone (1975) --- phosphoric acid sol in
conc. 20% to 50% applied to enamel for 60 sec,
create most retentive conditions.

 Clinical studies have verified that 20 sec etching
time produces retention rates comparably with
the conventional 60 sec .
 Fusks at al (1984) reducing etching time to 20
sec does not increase marginal leakage.

RETENTION RATES FOR SEALANTS
PLACED ON PERMANENT AND
PRIMARY TEETH
1)occurance of prism less enamel in primary
teeth
2)presence of more exogenous organic material
with in the rods of primary enamel
3)lower mineral content and higher internal
prism volume.

 To improve the retention rates for primary teeth
--- increasing the acid etching exposure time ---
60 to 120 sec.
 Recent studies on primary teeth --- retention
rates more comparable with those in permanent
teeth.

CLINICAL PROBLEMS ASSOCIATED
WITH SEALANT USE
1)Lack of universal usage
2)Technique sensitivity
3)Caries susceptibility of etched enamel
4)Detection of lost sealant
5)Inadvertent placement over active carious sites

LACK OF UNIVERSAL USAGE
 American Academy of pedodontics (1983) and
The National institute of health (1984) ----
developed guidelines for use by the practitioner.
 To achieve greatest possible caries reduction.
 A comprehensive caries – preventive program
must use sealant in conjunction with other
caries preventive methods.

 ADA (1987) --- Pt selected for sealant placement
must
1)be dependable on recall appointments
2) be motivated and proficient in caries control
3) have a low caries activity
4) receive systemic and topical fluorides

 Pt. oriented selection system relies on
exercising prudent clinical judgment.
 Simonson (1984) --- caries free and
caries rampant pt. left unsealed.
 Ripa (1985) --- all children considered
potential candidates for sealants.

SURFACE
DIAGNOSIS
CLINICAL
CONSIDERATIONS
DO SEAL DO NOT SEAL
Carious Occlusal anatomy If pits or fissures are
seperated by
transverse ridge ,
sound pit and fissures
may be sealed.
Carious pits and
fissures
Questionable Status of proximal
surfaces
Sound carious
General caries activity Many occlusal
lesions ,few proximal
lesions
Many proximal
lesions
Sound Occlusal morphology Deep narrow pits and
fissures
Broad ,well coalesc
ed pits and fissures
Tooth age Recently erupted
teeth
Teeth caries free
for
4 yrs or longer
Status of proximal
surface
Sound carious
General caries activity Many occlusal
lesions ,few proximal
lesions
Many proximal
lesions

Success of sealant retention based on
tooth selection
Factor counterpart
Older(10-14 yrs) Younger(5-8 yrs)
Permanent >primary
Mandibular >maxillary
Premolars >molars
occlusal > Buccal or lingualwww.indiandentalacademy.com

TECHNIQUE SENSITIVITY
 Strict and meticulous adherence to the
manufactures recommendation for placement is
critical.
 The quality of etch and sealant coverage and
polymerization --- influenced by quality of
isolation.

DETECTION OF LOST SEALANT
 Partial loss of sealant potentially exposes the
terminal ends of fissures , inducing
microleakage and enhancing cariogenesis.
 Opaque sealants

CARIES SUSCEPTIBILITY OF ETCHED
ENAMEL
 Non sealed, etched enamel is not more
susceptible to caries formation
 Etched enamel remineralizes completely within
48 hr .
 Following sealant loss , there appears to be
initial cariostatic benefits to the occlusal
surface.

INADVERTENT PLACEMENT OVER
ACTIVE CARIOUS SITES
 Going et al (1978) 89% active caries test sites ---
sealed become sterile.
 Improvements in sealant retention and
decreased viability of bacteria --- provide
therapeutic and prophylactic value .

OCCLUSAL SEALANT TECHNIQUE
 Recommendations for use
1) be dependable on recall appointments
2) be aged 6 to 15 yr
3) be motivated and effective in caries control
4) have low caries activity
5) have eligible teeth

MATERIAL SELECTION
 Several products available and vary as
1) acid concentration
2) means of polymerization
3) composition and setting times
 Acid conc. Varies between 35 – 50 % and this
range conc. has no indication to affect on
clinical performance

 Method of polymerization --- have effect on
clinical performance of sealant.
 Fairhurst et al (1984) --- auto polymerized
sealant superior to ultraviolet light – activated
sealant.
 Shapira et al (1990) --- no difference in retention
between an auto polymerized and visible light
activated sealant.

PLACEMENT TECHNIQUE
1) Isolation
2) Cleaning
3) Etching
4) Washing and drying
5) Application
6) Evaluation
7) Adjustment
8) Re-evaluation

Isolation
1.Cotton rolls may be used
for
isolation , but a rubber
dam
is preferred.
2.After adequate isolation is
obtained, the surface is
dried
and re examined for the
presence of any caries
lesion.

Cleaning
 1.A prophylaxis is
performed with a
Non fluoride oil –
free paste .
 2.Tooth is rinsed
with water
thoroughly.

Etching
 1.The pellet is applied
to the enamel surface
for 20 to 60 sec using
a continues
application of fresh
acid.
 2.A safe and effective
alternative would be
to use gel instead of
a solution.


Washing and Drying
The surface is rinsed with
Water for 10 sec and then
Dried for an additional
10 sec being careful not
to use an oil – contaminated
Air syringe.

Application
1.The sealant is carried to the
Surface and applied smoothly
2.The sealant is allowed to
flow ahead into the crevices
from one end of the tooth to
the other.
3.This minimized entrapment
Of air bubbles better than a
Brush – on technique.

Evaluation
1.An attempt to remove the
sealant with an explorer to
determine if adequate bond
strength is established.
2.The use of this immediate
test of retention has resulted
in excellent future retention
rates .

The sealant should completely cover the
occlusal surface.

Adjustment
 Slight occlusal interference should of no
concern with unfilled sealant.
 Filled sealant should be adjusted with green
stone.
 Fluoride treatment should follow, not precede ,
sealant application.

Preventive resin restoration
 It integrates the preventive approach of the
sealant therapy for caries susceptible pits and
fissures with the therapeutic restoration of
incipient caries with composite resin that
occurs on the same occlusal table.

Re evaluation
 Sealants should be examined for loss every 6
months .
 Bite wing radiographs -if microleakage has
occurred since placement.
 Completely lost sealant
 Partially lost sealant

Preventive resin
restoration
 It integrates the preventive approach
of the sealant therapy for caries
susceptible pits and fissures with the
therapeutic restoration of incipient
caries with composite resin that occurs
on the same occlusal table.

 They are 3 types of PRR
Type A – suspicious pits and fissures where
caries removal is limited to enamel.
Type B – incipient lesion in dentin that is small
and confined
Type C – characterized by the need for greater
exploratory preparation in dentin

 Simonson (1978) advocated
an unfilled sealant --- type A
a diluted composite resin ----
type B filled composite resin
---- type C
 Ulvested (1976) adopted the concept of diluted
composite resin---- mixture of filled composite
resin and unfilled bonding agent over an
unfilled sealant.
 Use of an intermediate unfilled resin layer.

 Lebell and Forsten (1980)
 Shapira and Eidelman (1984)
 Houpt et al (1984) demonstrated by using an
auto polymerization filled resin over covered
with unfilled sealant in type B restorations.
 After 4 yrs reported that 76%of placed
restorations were completely retained.

Type A restoration
Enamel fissure caries are
removed with slow speed
Round bur.
Enamel surface is etched
completely with sealant.

Placement technique
 Type A restoration
1)clean the surface
2)isolation
3)remove decalcified pits and fissure
4)place acid – etched gel – 20 to 60 sec
5)wash and dry
6)apply the sealant
7)polymerise with visible light – 20 sec
8)adjust the occlusion, if neededwww.indiandentalacademy.com

Type B restoration

Placement technique
 Removal of caries
 Application of acid – etching gel
 Bonding agent application
 Injection of filled composite resin
 Condensation and smoothing
 Filled sealant application
 polymerization

Removal of caries
1.With a high speed no.330 bur,
followed by a slow speed no.1/2
Round bur.
2.After caries removal Ca(OH)2
liner is placed .

Acid etching
Acid etching gel is applied over
the entire occlusal surface for
20 to 60 sec , then washed 20
Sec and dried 10 sec.

Bonding agent application
The walls of the preparation
are coated with bonding agent
which act as an intermediate
Resin layer.

Composite resin application
Filled composite resin is
injected into the preparation
and placed.

Resin condensed and smoothened by
plastic or Teflon instrument
The composite resin is
condensed and smoothed
with a plastic or teflon
Instrument.

Sealant application
Filled sealant material is
Applied over the entire
Occlusal surface.

Polymerization
All layers are simultaneously
Polymerized with visible light
Produced by the
Polymerization unit.

Occlusal adjustment
The occlusion is adjusted,
Where required, with
finishing burs.

Type C restoration
 Repeat all steps listed for type B
 Type C is larger and deeper add additional
polymerization time (30 sec).
 In most cases local anesthesia will also be
required.

CONCLUSION

Sealants & preventive resin restorations / dental courses

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