Arresting occlusal enamel caries lesions with pit and fissure sealants
Pit & fissure sealants (1)
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Pit and Fissure Sealants
Cara Miyasaki-Ching, RDHEF, MS
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Legal requirements RDA, RDAEF – DDS decision or supervision RDH, DDS/DMD – General supervision Sealant adjustments
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Requirements - minimum
16 clock hours total 4 hours of didactic
training 4 hours of laboratory
training 8 hours of clinical
training
Student shall: Have current CPR Take a written exam RDA or RDA eligible
(this includes coronal polish)
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Requirements - continued
Patient 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
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Certification Requirements
Successful completion of written exam Successful completion of laboratory and
clinical portions of the course
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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
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Why pit & fissure sealants needed
Bacteria produces acid which causes decay
“demineralization”
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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
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Effectiveness of sealants
15 year study – 68% of sealed teeth were caries free vs 17% of unsealed control group
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Other Preventive Programs
Community water fluoridation
School water fluoridation
Fluoridated toothpaste Fluoride mouthrinse In-office treatment
50-60% (18-40%)
40% 15-30% 31% 26%
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Preventive Programs as Related to Sealants Tooth brushing and flossing - mechanical
plaque removal Fluoride – chemical prevention Dental visits – mechanical plaque removal
and chemical prevention
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Preventive Programs as Related to Sealants - continued
Diet Minimize exposure to cariogenic foods and
liquids that have little or no nutritional value
Minimize solid and sticky foods Minimize slowly dissolving foods
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History of Sealants
Acrylic polymers introduced to dentistry – 1937
Composites - 1960 “Occlusal Sealing” – 1965 Glass ionomers – 1972
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Retention of Sealants – 4 year study
Fluoride releasing sealant
91% retention (77% complete & 14% partial)
10% caries rate
Non-fluoride releasing sealant
95% retention (89% complete & 6% partial)
10% caries rate
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Retention of Sealants – 2 year study
Fluoride releasing sealant >90% retention No caries
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Sealant retention
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Sealant Failure
Debris and/or saliva contamination Air inclusion during manipulation – voids Manipulating self-cured sealants late in the
setting reaction
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Loss of Sealant
A contaminated site from faulty technique will likely result in complete or partial loss of the sealant within 6-12 months.
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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
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Preventive Resin Restoration
The preparation of fissures by use of air abrasion, bur or laser followed by filling the prep with a flowable composite.
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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
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Tooth morphology
Pits and fissures
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Tooth morphology
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Tooth morphology
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Tooth morphology
Why fissures are caries susceptible
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Selection of teeth
Considerations Patient age Oral hygiene Caries risk Diet Fluoride history Tooth type Morphology
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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
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Indications
Deep fissures Incomplete or ill formed pits Newly erupted teeth High caries rate Children Molars
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Contraindications
Shallow fissures Well coalesced pits Fluoride rich enamel Low caries rate Occlusal or proximal caries Adults
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Partially erupted teeth?
To seal or not to seal?
Operculum (gum flap) – leaks crevicular fluid
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Sealant Kits
Cavity Indicators Drying and/or bonding agent (optional) Acid etch Sealant material
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Acid Etch
Gel Liquid 3M Innovation:
Adper™ Prompt™ L-Pop™ Self-Etch Adhesive
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Acid etch Phosphoric acid 35%-40%-50% Dissolves organic portion of
enamel “micromechanical retention”
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Acid etch - continued Creates more
surface area for better adhesion
Also high energy surface
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Acid etch - Precautions
Avoid contact with adjacent teeth or soft tissues
Can use mylar strips or matrix bands
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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.
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Acid etch – storage and handling protocol 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.
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Acid etch - continued
Will an etched tooth be more prone to decay?
Remineralization begins after 24 hours
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Drying agent (PrimaDry)
Acid etching and Primadry (alcohol based) allows enamel to be easily “wetted”
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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.
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PrimaDry – storage and handling protocol 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.
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Sealant composition
A type of specialized plastic (resin) or glass ionomer material
Matrix Filler
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Sealant Types
Resin Sealants (Bis-GMA) Bisphenol
A-glycidyl methacrylate resins
Urethane-based resin
Glass Ionomer Sealants Anticariogenic More viscous, less
retention, more brittle and less resistant to occlusal wear
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Sealant Types
Filled sealants Unfilled sealants
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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
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Types of curing for sealants
Chemical cured – “autopolymerization” Base and catalyst
Monomer & Initiator + Diluted monomer & 5% Organic Amine Accelerator = Sealant
Visible light cured – “photopolymerization” Pre-mixed
Dimethacrylate + Diluent + Activator + Light = Sealant
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Chemical cure sealant materials
Advantages No cure light or risk of eye damage Can apply sealants to several teeth
Disadvantages Variation in setting time (appx 2 min) Voids from mixing material Changes in viscosity over time
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Light cured sealant materials
Advantages Short setting time (appx 20 seconds) No mixing required Won’t set-up – longer working time Does not get thick
Disadvantages 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
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Sealant Shades
Clear Tinted Opaque
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Clinpro™ Sealant goes on pink for easy-to-see application, and cures to a natural white.
low viscosity, fluoride-releasing sealant
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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
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Sealant Material – storage and handling 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.
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Concepts of bonding
Mechanical bonding – interlocking Chemical bonding – use of adhesive Physical bonding – attraction of atomic
charges
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Requirements for Adhesion
Clean surface Good wetting by adhesive Good adaptation to the substrate Good interface Good curing
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Strength and Viscosity Characteristics
Viscosity The thicker the sealant the
less likely to penetrate to depth of fissure
Wear of Sealants Considerations for wear –
less filler, more wear and visa versa
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Curing units
Conventional cure light with halogen bulb = 20 seconds cure for each surface
Plasma arc or laser = 5-10 seconds
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Assemble armamentarium
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Assemble sealant kit
Check the operation of the syringe on gauze
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Armamentarium
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Curing units
CAUTION – Avoid looking directly at the light
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Give patient instructions
Verbal 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
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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.
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Wear personal protective equipment - operator Gloves Mask Safety glasses/visor Protective clothing Closed toed shoes
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Wear personal protective equipment - patient Safety glasses Pt. glasses should be
tinted when using a curing light (operator/assistant should have tinted glasses on shields)
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Position patient
Mandibular Maxillary
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Check prescription and teeth Occlusal surfaces Buccal and lingual pits
on first molars Lingual pits on upper
anterior teeth
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Suspicious lesions?
Explorer – “a stick” Caries indicator dye DIAGNOdent
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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
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Prepare the Tooth - continued
air abrasion, bur, prophy jet or laser
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Position the patient
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Check occlusion
Avoid placing acid etch and sealant on marked areas from articulator paper
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Isolate tooth/teeth
Treat quadrants separately
To control isolation To prevent
contamination by moisture
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Isolate tooth/teeth Rubber dam Cotton rolls Cotton roll holders Dri-angle
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Dry tooth
Test air/water syringe before applying blast of air
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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
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Apply acid etch - continued
3M Innovation: Adper™ Prompt™ L-Pop™ Self-Etch Adhesive
Etch, prime and bond
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Apply acid etch Etch pit and fissures Extend 1-2 mm beyond
pit and fissures Avoid cusp tips
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Acid etch - continued
Etch longer Deciduous teeth Saliva contamination Air abrasion or prophy
jet used Highly mineralized
teeth
Do not use explorer
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Rinse tooth/teeth
Use HVE and a/w syringe
Proper – usually 20 seconds rinse
Avoid saliva contamination
Re-isolate
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Dry tooth/teeth
Should appear chalky or frosty white if etched
If not, re-etch for another 10 seconds if not contaminated
with saliva
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Apply drying agent (PrimaDry)
Use brush tip Apply and leave for 5
seconds Gently blow air to dry DON’T RINSE
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Apply bond agent
A bond agent will improve retention
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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
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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…..yet
Note: sealant will appear shiny/wet
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Light cure for 20 seconds – air inhibition theory Top layer of sealant
will remain uncured sealant will appear
shiny/wet
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Check sealed teeth
Use explorer Tooth should be
smooth but not soft Re-apply sealant, if
necessary
(Remove uncured sealant with wet cotton roll)
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Remove isolation materials
Moisten Dri-angle Rinse the patient’s
mouth
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Check occlusion & contact(s)
Articulating paper Dental floss Ask patient how it
feels Dentist can adjust with
bullet-shaped finishing bur or polishing stone
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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)
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Documentation
9/1/05 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.
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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
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Common Problems
Re-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
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Failure of sealants
Main cause – moisture contamination
Maxillary and mandibular 2nd molars
Early loss means less retention of the resin
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Sealing over caries
For incipient caries – risk of progression is very small
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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
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Sealant maintenance
Loss of all or part of the sealant
Staining at edges
Discoloration underneath sealant
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Repair of sealant
Reapply if totally lost
Repair partial loss Roughen with
diamond stone Re-etch 20 seconds Reapply sealant
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Finished!