Clinical Aspects of Dental Sealants:

Materials and Application

National Primary Oral Health Care Conference

Kevin J. Donly, DDS, MSProfessor and Chair

Department of Pediatric DentistryUniversity of Texas Health Science Center

at San Antonio

70% of molars (years 1950–1980)

develop occlusal caries

(Eklund and Ismail, J Publ Health Dent, 1986)

Lewis and Hargreaves (1975)

Investigated occlusal caries in permanent first molars in a four year longitudinal study of 142 five year old children (Fluoride < 0.1 ppm).

Age % of 1st Permanent Molars Carious 6 64

7 80

8 93

CLINICAL STUDIES OF Bis-GMA SEALANTS

Study TimeSealant

Retained*Caries

Reduction

mos % %

* Completely present, data for permanent teeth

Roydhouse40 36 29Buonocore9 24 87 99

Rock38 24 80 99

Horowitz et al.22 24 73 67

Courley19 24 78 57

Merrill et al.33 15 55

Going et al.18 24 69 55

Meurman & Heiminen34 36 80 88

Occlusal caries in children have significantly decreased

Third National Health and Nutrition Examination Survey

Changes in Occlusal Caries Rates (4 years after Eruption)

55

15

68

25

0

10

20

30

40

50

60

70

80

90

100

1971-74 1988-94

U.S. Health Surveys

Perc

en

tag

e o

f Teeth

wit

h O

cclu

sal

Cari

es

1st Molars

2nd Molars

Changes in Occlusal Caries Rates (4 years after Eruption)

55

15

68

25

0

10

20

30

40

50

60

70

80

90

100

1971-74 1988-94

U.S. Health Surveys

Perc

en

tag

e o

f Teeth

wit

h O

cclu

sal

Cari

es

1st Molars

2nd Molars

Changes in Occlusal Caries Rates (4 years after Eruption)

55

15

68

25

0

10

20

30

40

50

60

70

80

90

100

1971-74 1988-94

U.S. Health Surveys

Perc

en

tag

e o

f Teeth

wit

h O

cclu

sal

Cari

es

1st Molars

2nd Molars

Changes in Caries Levels in U.S. Health Surveys (Early 1970s to Early 1990s)

Changes in Caries Levels in U.S. Health Surveys (Early 1970s to Early 1990s)

Is There a Need for Dental Sealants?

84%

16%

OcclusalAproximal

Occlusal vs. Aproximal Caries in the USA

Burt, et.al. IDR 67, 1988, p.1422

15-Year Single Sealant Application Recall

(Simonsen, JADA 122:34-42, 1991)

Retention of White Sealants by Surface on Permanent First Molars

5 Years 10 Years 15 Years

Complete retention 82% (173) 56.7% (131) 27.6% (53)

Partial retention 10.9% (23) 20.8% (48) 34.5% (68)

Missing 0.5% (1) 6.9% (16) 10.9% (21)

Restored/ carious 6.6% (14) 15.6% (36) 26% (50)

Total 100% (211) 100% (231) 100% (192)

Sound vs. Carious or Restored Surfaces on Permanent First

Molars at 15 Years

Group withSealant

Group withoutSealant

Sound surfaces 68.8% (88) 17.2% (22)

Carious orrestored surfaces

31.3% (40) 82.8% (106)

Total surfaces 100% (128) 100% (128)

Matched pair analysis (n = 128 surfaces, 16 subject pairs)

5-Year Study; Fluoridated Community

o Sound Surfaces- Non-sealed – 13% caries- Sealed – 8% caries

o Incipient or Questionable Surfaces- Non-sealed – 52% caries- Sealed – 11% caries

(Heller et al, J Publ Health Dent, 1995)

Indications for Sealantsto Prevent Occlusal Caries

Workshop on Guidelines for Sealant Use

o Caries risk assessment of the individual and the tooth are important as determinants of sealant need.

o Caries risk on surfaces with pits and fissures may continue into adulthood; therefore, post-eruptive age alone should no-longer be used as a major criterion for sealant decisions.

o Sealants should be used to prevent caries in at-risk teeth (preventive sealants).

o Sealants should be used to treat teeth with questionable caries or definite caries confined to the enamel pits and fissures (therapeutic sealants).

o Sealed teeth need to be evaluated periodically for sealant integrity and retention.

(Siegal, J Publ Health Dent, 1995)

AAPD Recommendations

The dental literature supports:1. Bonded resin sealants, placed by appropriately trained

dental personnel, are safe, effective and underused in preventing pit and fissure caries on at risk surfaces. Effectiveness is increased with good technique, appropriate follow-up, and resealing as necessary.

2. Sealant benefit is increased by placement on surfaces judged to be at high risk or surfaces that already exhibit incipient carious lesions. Placing sealant over minimal enamel caries has been shown to be effective at inhibiting lesion progression. Appropriate follow-up care, as with all dental treatment, is recommended.

3. Presently, the best evaluation of risk is done by an experienced clinician using indicators of tooth morphology, clinical diagnostics, past caries history, past fluoride history and present oral hygiene.

4. Caries risk and, therefore, potential sealant benefit, may exist in any tooth with a pit or fissure at any age, including primary teeth of children and permanent teeth of children and adults.

Mertz-Fairhurst et al. Cariostatic and Ultraconservative Sealed Restorations: Nine-Year Results Among Children and Adults. ASDC J Dent Child, 1995

vs.

Weerheijm et al. Sealing of Occlusal Hidden Caries Lesions: An Alternative for Curative Treatment? ASDC J Dent Child, 1992

Minimal Decay vs. Extensive or Rampant Decay

Importance of screening children in School-Based Sealant Programs and referring those to a Dental Home most in need of comprehensive dental care.

Types of Sealants

Self cure Light cure Unfilled resin Filled resin Color changing Self etching Fluoride releasing

Clinpro Sealant (3M ESPE)

Helioseal Clear Chroma (Ivoclar)

Self Etch Sealant and Hydrophilic Sealant

Fluoride Releasing Sealants

o Glass Ionomero Fluoridated Resin

Lesion Initiation (Mean ± S.D.)

Control Sealant 138 ± 18µm Fluoride Sealant 109 ± 21µm GIC 83 ± 12µm

(Hicks & Flaitz, Am J Dent, 1992)

Acid Etch vs. Air Abrasion

Kanellis et al., 2000 (J Pub Health Dent) Berry and Ward, 1995 (Quintessence

Int)

How Long Should Primary Enamel be Etched?

Redford, Clarkson and Jensen, 1986 (Pediatr Dent)

Etch Depths (microns) in Primary Enamel after Different Etching

Times with 37% Phosphoric Acid

Etch Times

15s 30s 60s 120s

Mean Depth 9 12 14 50

Bond Strength (kg/cm2) of Sealant after Different Etching Times

Etch Times

15s 30s 60s 120s

Mean 92 92 83 83

S.D. 177 161 142 145

# of Samples 13 21 17 13

5. 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.

6. A low-viscosity, hydrophilic material bonding layer as part of or under the actual sealant has been shown to enhance the long-term retention and effectiveness.

Enameloplasty

Air abrasionMinimally invasive burs

Bonding Agent Prior to Sealant Placement

Hitt and Feigal, 1992 (Pediatr Dent) Feigal et al., 1993 (JADA) Feigal et al., 2000 (J Dent Res)

PRIME & BOND 2.1 (Caulk/Dentsply)

Sealant Placement Technique At risk surface Tooth isolation Clean surface Etch with 35% phosphoric acid for 15–30

seconds Bonding agent Place sealant Cure sealant Check occlusion Re-evaluate

ONE-STEP®(Bisco)

7. Glass ionomer materials can be used as transitional sealants, and may prove to be effective as longer-term pit and fissure sealants.

8. The profession must be alert to new preventive methods effective against pit and fissure caries. These may include changes in dental materials or technology.

Glass Ionomer Sealants

Bisphenol A90–931 µg/30 ml saliva

Environmental Health PerspectivesMarch 1996

1. 50% uncured bisphenol A leaches within 3 hours (Ferracane, 1990).

2. Saliva dose not equal to blood dose.

3. Estrogenic effects in breast cancer cells, not normal cell culture

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