Fissure sealants in dentistry

Im just going to repeat the last slide from the last lecture; before you do a Fissure sealant FS you should take a bite wing x-rays BW RGs even if the teeth looks clinically sound to you, in order to check if there is inter-proximal caries, once you have excluded inter-proximal caries you go on with the pit and fissure sealant, if you see on the x-ray that there is a dentin involvement then it means that we need to do restorations in proximal lesions like class II restoration and if there is occlusal lesion it becomes a PRR preventive resin restoration or class I restoration.

Acid etching The ideal acid etch combines the least loss of surface contour with the greatest depth of histologic change. The most effective acid etching is between 30-40% and the one that we usually use is 37% phosphoric acid, the type of acid has no influence on retention of the sealant. 15 seconds etching time is enough in primary and permanent teeth. We can use the gel form or the liquid form, the difference between them is that the gel form is easy to contain and to manage but the penetration of the liquid form is better into the tissues, but we still use the gel form with children, it is easier to perform.

Sealant types There are seven generations of sealants.. - The first generation cured through ultraviolet light and it is no longer available. - The second generation cured by automatic chemical reaction. - The third generation cured by visible light. - The fourth generation has fluoride incorporated in it. Now we are working with the most advanced generation which is the one that cured by visible light.

Sealant is an unfilled resin, and the resin can be any type of resin that you have learned in dental materials course (Bis-GMA, UDMA,TEGDMA). The glass ionomer cement GIC was also introduced as a sealant in 1970s. The sealant as a sealant can be either a filled or un-filled resin, there are differences in terms of retention, the filled type has better retention, but the occlusal adjustment is a little bit more difficult with the filled type because it is hard. The colored vs clear type, the colored is usually white in color and still we have it in the clinic The clear type is clear like glass, like we put a layer of glass on the surface of the tooth so it is a bit hard to detect when you are examining the patient clinically. Now about auto cured and light cured, the effectiveness and the retention of the visible light cured is similar to that of auto cured but now it is no longer used the auto cured. Light cured has less marginal leakage.

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According to fluoride gel application, fluoride can be placed before or after FS. If you have a patient and you want to perform a fluoride gel application you can do it before or after FS, but in the clinic we ask you to do it at the end of everything after FS, because if you want to fissure seal you have to wash it with water and that will remove the fluoride gel, so practically it is not applicable. As Dr said Dont tell me then that u want to do F gel application then FS and now you that you have to do FS then F gel application This is an example of a GI fissure sealant, it is called fuji VII slide # 23 Fuji has seven types of products of GIs, there is fuji I,II, VII and IX. Fuji VII is pink in color and it is usually used as a FS, we usually use it in partially erupted teeth, because the moisture control is difficult in those teeth, it is placed in the grooves of the teeth, it is normally release fluoride and it comes in pink and white. Glass ionomer GI as a sealant has poorer retention than the resin type because with the resin you do acid etching and you will get micro-mechanical retention to the resin tags, but GI binds only by chemical adhesion between the GI and the tooth so it is not very effective in retention.
The types in the terms of acid etching are resin type then we have GIC type and then we have resin modified type which is a vitremer.

The best is the resin in the term of retention, the weakest is the GIC, it is the least retentive and it also wears and leaks, but resin modified glass ionomer cement RMGIC comes in the middle it has better retention than GIC but poorer than the resin type so it comes somewhere in between. The GIC and vitremer rmGIC FS are indicated in partially erupted teeth because moisture control is difficult in these cases.

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This is also an example slide # 24, this is a fuji VII on a hypo-plastic teeth, before they come into full occlusion there would be sever attrition and loss of occlusion and vertical dimension. So we use fuji VII in these teeth to protect them also to maintain the occlusal vertical dimension.

The Technique Isolation is very very important, if you do not have enough isolation do not even think about FS, then clean the tooth surface, prophylaxis is enough, if the patient has good oral hygiene and brush his/her teeth then you do not have to do any prophylaxis. Some people go to the extremes of air abrasion and enameloplasty, yes they have better penetration in the resin but they are expensive and abrasive so we do not use them. Etching ,it is the third step after you isolate the tooth and clean it, then you wash the etchant and dry it, then apply the FS, finally adjust the occlusion. So the steps are : IsolationCleaningEtchingWashing and DryingApplication of FSAdjustment of occlusion

Of course isolation is best obtained by the rubber dam, in the clinic we do not use rubber dam, we usually get to use cotton rolls, so u have to put cotton rolls on the buccal and lingual sides if you do it on a lower tooth, also you need the suction.

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In the clinic usually you will be working in pairs, so the operator usually has the mirror for retraction, the partner usually has a tongue depressor-get it from dispensary- for retraction So if you working on a lower tooth, one of you will retract the cheek the other will retract the tongue, it is a double fold retraction. In the lower arch it is a little bit more difficult. The assistant also has to hold the suction.Clinically you must be A WARE of that, then you will start with your technique if you have good isolation then you can do it. With the upper arch you put a cotton rolls buccally and also one of you will retract the cheek and the other will retract the tongue, the one who is at the side of the tongue will retract it and the other who is at the side of the cheek will retract it, depends on which side you are working. So first of all isolation, maintain good isolation and then apply your acid etchant, we usually apply it up to 20 seconds then rinse it at least for 20 seconds, make good wash then dry it, you should get this sort of white chalky appearance at the surface of the tooth, then apply the sealant to the pits and fissures without altering the occlusal height that means you should not go to the cusps slopes and cusps tips, only in the fissures, so exactly trace the fissures with your FS. After that, you do light cure and any un-filled sealant will wear within one week. Finally you light any excess material on the tooth surface, why? Because the recommendations are minimal curing for an extra 5-10 seconds to enhance polymerization and you delay polymerization for 7 seconds after application to increase the length of resin tags. - if isolation is adequateBe sure that you always maintain the intensity of light of the light curing machine We will be checking your sealant in two ways, first of all once we look at it we do not want to see any voids or bubbles, the second thing is we will try to remove the sealant with probe -try your best to remove it-, if it stays there then you did a great job, if it gets detached then you have to re-do your job, usually the problem is poor technique and poor moisture control.
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Clinical problems that might be facing you are with the sealant, it is a sensitive technique, detection of caries if there is a recurrent caries it is hard to detect it underneath the FS. If you lose a sealant and half of it still there and the other half is gone, what do you do?, is this sealant still doing the job? They say that there is remnant of the FS in the resin tags still do the job which will still be protecting the tooth, others say that a partial retained FS is no more doing the job as if no FS is there. There is a big debate on it, so to be on the safe side just re-fissure seal. Placement of FS over caries, in some cases we place FS over inactive carious lesions, incipient ones, the one which is not active, why? Because we believe that the acid etchant will eliminate about 75% of microorganisms and when placing a FS on it, you will isolate any remnants of organisms and they die eventually because they are isolated.

The efficiency of the FS depends on its retention, they say that the longest retention period that has been studied by Simonsen was 15 years and there was 50% of caries reduction and 37% of the FS was lost, which means that some FS can lasts for 15 years if they are placed properly. The retention is much better in premolars than molars because the isolation is better. There is no difference in retention between primary and permanent teeth. The cost is sometimes higher than amalgam fillings.

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the other thing that I want you to learn since we are doing this course as preventive course is that as long as you are doing all the preventive features and elements together the patient is gaining, how is that ? by applying FS, prescribing mouth rinses, chlorohexidine, fluoride, xylitol ,BPA..-we will talk about them later on-, there is a form of interactions between all of these things especially fluoride in drinking water and FS in preventing caries, so if the patient gets all of these things together he will get a good result.

Safety issues
We will talk about safety issues regard fissure sealants and drawbacks or any concerns when you place a fissure sealant for a patient. - Fissure sealant releases estrogen like material called Bis-phenol A -Sometimes a parent will come and tell you please dont put a fissure sealant for my child because Im concerned about estrogenicity. Estrogenicity is an issue concerning not just fissure sealants even bottled products and caned products. But there is an estrogen which called estradiol-hormone which produced by the testes and ovaries in the body and responsible in the reproductive tract.

-phenol A : Is xenoestrogen, so it mimics the natural estrogen that we have in our body. So structurally its different from estrogen but it has a similar action. It has a role in breast cancer and decreased sperm counts. So it has a similar role of estrogen but in harmful way. It's present in the lining of food and drink cans, pesticides and preservatives. - when testing the estogenicity of the fissure sealant, Olea N et al. said that Bisphenol-A (which is present in fissure sealant) is not a direct ingredient of fissure sealant. Its the chemical that appears when raw materials fail to fully react and
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residual monomers leak out of the cured resin, this happens when we place a fissure sealant and dont light cure it enough (you should wait 20 seconds-the full cycle), otherwise you will have raw monomers leaking out of fissure sealant and causing less productivity into the saliva . -So Bis-phenol-A is estogenic . -** Monomers may be detected after one hour of placing fissure sealants in saliva.

Fung said he calculated the amount of Bisphenol-A which leaks from fissure sealants into the blood stream. He said if this amount is enough to cause xenoestrogenicity and cause harm, In vitro you need 2g/kg body weight/day.

After fissure sealing a tooth he said that only 1/1000 of Bispheola-A is released, this in not absorbed and may be present in non-detectable amounts in systemic circulation. So as conclusion he found that : No foundation for concern about estrogenicity of fissure sealants. -But if you have a concerned parents, the way that you explain things to them, you should tell them that there is no concern the amount that's leaking from fissure sealants is not enough to cause any problem. However to reassure them and make them feel safe you can do certain precautions while you are doing the procedure. -A suggestion for clinicians who wish to minimize patients' exposure to uncured components after fissure sealant would be to pumice with cotton roll on sealant surface after polymerization or as prophylaxis with rubber cup, the other thing give extra 5-6 second cure to ensure that everything is cured. -As result ,, you should cure fissure sealant with full cycle so you dont have any raw monomers, And just in case after you finished a fissure sealant you should wipe it with cotton roll which will be applied to the tooth and that will remove any access.
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Failure of Fissure sealants

1- Moisture contamination 2- Trapped voids, when you leave a void in fissure sealant. So when you put fissure sealant you have to be careful to brush it through the fissures without causing any voids and then cure it. 3- Wear, when you have a bruxism patient may be biting on his teeth hard, and he will develop wear more quickly than other patient (something we can't control it). 4- Marginal leakage ( secondary caries), this happens to all resins if your techniques were not meticulous. If you didnt bring attention to moisture contamination or dont wash acid properly or cure properly, you will get marginal leakage and sometimes you can get secondary caries underneath it and recurrent caries. 5- Polymerization shrinkage, this happens with all resins and you cant really do much about because is properties of materials but you can minimize it by meticulous technique and when you light cure try to be as much as possible closed to the tooth.

Follow-up
We have to check it if the sealant is bonding well and returned on tooth surfaces.

have any fracture part we have to re-applied.

Prevention resin restorations : PRR/CAR

Another term for this kind of restoration is the CAR conservative adhesive restoration they changed the name because the first one was the preventive resin restoration only for resins/composite but CAR is for resin/composite plus other adhesive materials such as GIC or resin modified glass ionomer . So We will start with pits and fissure caries only the class I (minimal caries), so we need to restore these teeth or fissure seal, Blacks guidelines for preparing a
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cavity in class I indicate that you have to extend it to all fissures and grooves, in order to have a retention and resistant forms. Now to be conservative, we can just remove the caries whatever it is and however it is, you just follow the caries and remove it then you stop, you dont have to extend to all the fissures & the grooves, after that you acid etch, bond then place your composite, so this type of design is for adhesive materials (obviously not for amalgam) .

We have 3 types of restorations based on the extent of caries & determines the restorative material:: 1. Type 1 : you are only in enamel, investigated with a round bur in the enamel its also called enameloplasty, then you can just place a fissure sealant if its a little bit deep you place composite resin then FS, no LA is required. 2. Type 2: they extend beyond CEJ defend to the dentin (small) & LA is preferable(optional) , when you are in dentin we always place GIC either as a filling or a liner then top it with fissure sealants ( GIC & FS) 3. Type 3: the extent in dentine is (deep) & LA is a must (GIC & FS) or (GIC, CR & FS). . There are four different combinations of materials used:

GIC+CR+FS *Note: it can be GIC or resin modified GIC.

Fluoride-I
We will talk about the mechanism of action of fluoride..
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Fluoride was detected in human dental enamel in 1805 and waterborne fluoride was detected by Berzelius in 1822. Fluoride containing dentifrices (tooth-paste) they became available at least as early 1902.

Absorption and distribution

(GIT). one hour of ingestion. We care about that because in case of F toxicity if we have a child swallow a full pocket of fluoride agent or a tube of tooth-paste, that will be worse and you have to act within an hour because some symptoms will happen.

Flouride & hard tissue:

Flouride has a strong affinity for Ca salts especially Ca-Phospahte (present in the teeth) and become incorporated into bone & teeth during dental development. It becomes incorporated into bone at all the time ,but into teeth only during their developmental processes after that it cant be incorporated into the structures of the teeth. It can be topically applied, superficially from enamel. Bone is the major reservoir for F deposition in the body. Fluoride not immediately incorporated in hard tissue, and its rapidly excreted in urine and to a lesser degree in sweat & feces

teeth have been fully formed, negligible amounts of F incorporate by continued apposition of cementum. There may be some F in the tooth (after the tooth has been fully formed) only if the root still continues its formation. calcium Fluoraptite. (Ca+ phosphate +F) .

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Effect on dental caries

-50% less dental caries in areas where the drinking water contains about 1 ppm of water fluoridation and this is compared to non-fluoridated areas.

Mechanism of action can be either: 1) Pre-eruptive (before the eruption of the teeth) 2) Post-eruptive (after the eruption of the teeth) ** no study has been conducted to prove that pre-eruptive fluoride incorporation is better (best to think that if you give fluoride at the beginning the teeth will become more resistant to caries and the benefit are excellent it can affect teeth) to that which can be incorporated during or after tooth eruption (post-eruptive). **fluoride after the eruption period is much more efficient, so the topical effects of fluoride are better than systemic effects. to caries develops mainly post-eruptively -eruptive mechanism of preventive topical effects of fluoridated water is cumulative; the longer the tooth is exposed to fluoride (even in water, toothpaste or mouthwash) post-eruptive, the greater you get resistance to caries, But once this stops you will have no resistance to caries. It lasts sometimes then goes ! fluoridate districts. dren (because its topical effects )

Pre-eruptive :
Two critical periods for fluoride incorporation into enamel; Secretory and Maturation stages of enamel : 1. During terminal stages of crown formation. 2. When the crown undergoes pre-eruptive maturely in the dental sac while being bathed in tissue fluids.

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Post-eruptive :
1. Through an effect on bacteria (streptococcus mutant in the saliva). 2. Through effect on the tooth surface.

Inhibition of dental caries by fluoride

Direct effect on development of enamel. Fluoride replaces OH groups and bind the hydroxyapatite (HA) crystals in enamel to form calcium fluorapatite (FA). Ca10 (PO4) 6(OH) 2 + 2F Ca10 (PO4) 2F + 2OH Hydroxyapetite >>> fluoroapatite

Fluorapatite effects :
1- fluoroapatite more resistant to solution of acid than Hydroxyapetite **( FA has more acid resistant- more caries resistant) . - So you get less soluble enamel with lower carbonate (CO3) content thats approve the resistance and the tooth become stronger.. - When enamel is acid-etch, Ca phosphate salt are re-precipitated and fluoride enhances possibility of their crystallizing as apatite, so the presence of fluoride in the enamel will favor the remineralization of the tooth structure after acid etching . Thats what we mean by that fluoroapatite enhances remineralization and decreases the demineralization. 2-Topical effect- fluoride in saliva interacts with bacterias (carious process) by 3 mechanisms: A. Antibacterial properties. B. Inhibits demineralization of of Ca& P in enamel of tooth. C. Enhance remineralization. **Remineralization occurring after demineralization makes the enamel surface more resistant to caries progression and strong structures.
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3- Effects on enamel surface has been suggested (but not generally accepted) that fluoride reduces the tendency of enamel surface to adsorb salivary proteins. 4- Effect of fluoride on bacterial plaque: this is important because fluoride incorporated into bacteria plaque and its ionize (F ions). The fluoride works as anti-bacterial agent, so if you have it in high concentration it can be acting as a bactericidal agent. **Fluoride affects bacterial metabolism & inhibits acid production, so it affects two enzyme: -It affects the bacterial metabolism by inhibition of glycolysis (which is important process produce ATP and lactic acid that affect tooth surfaces). So by inhibition of the enolase enzyme (that is a very important enzyme in the glycolysis process), so the glycolysis is stopped and the bacteria will die. - Another direct anti-bacterial effect by inhibition of the ATPase enzyme causing defects in the H+ pump of the cell (which responsible to pump access H+), leading to increased H+ in the cell (decrease pH) so the bacteria is dying .

Fluoride concentration
The optimal concentration of fluoride through each day is that if it's present in both the tooth surface and saliva so it will control caries. Therapeutic dose of fluoride Clinical and laboratory studies suggest that you need 0.1 ppm of fluoride all day and night will give you a excellent protection against caries progression -70% caries reduction in high risk patients that given 0.1 or 0.11ppm ,versus controlled patients over two years given 0.03ppm. Different studies suggest different numbers of the therapeutic levels of fluoride plus there is no way of maintaining this unless the patient is regularly applied fluoride (either toothpaste, mouth rinse or any fluoride products).

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Fluoride therapy
*Systemic : -Water fluoridation: is the most effective method of getting fluoride. Because its going to be available to everyone, if the government fluoridate the water tap water make them clean enough to drink it, then everyone will be getting fluoridated water the caries reduction from water fluoridation is somewhere between 50% -70% and that was based on a study in the USA .

**sorry for being too late but we were just waiting the slides !
**there are some slides still not available ! **we added some additional notes from2009s script !

Good luck : ) Done by Malak Abu-aqulah & Rahaf Hasan

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