Dental sealant

Dental sealants (also termed pit and fissure sealants,[1] or simply fissure sealants)[2] are a dental treatment intended to prevent tooth decay. Teeth have recesses on their biting surfaces; the back teeth have fissures (grooves) and some front teeth have cingulum pits. It is these pits and fissures which are most vulnerable to tooth decay, partly because food sticks in them and they are hard to clean areas. Dental sealants are materials placed in these pits and fissures to fill them in, creating a smooth surface that is easy to clean. Dental sealants are mainly used in children who are at higher risk of tooth decay, and typically they are placed as soon as the adult molar teeth come through.

Background

Back teeth showing fissure system

Dental caries is the balance between loss and gain of minerals from a tooth surface.[3] The loss of minerals from our teeth occurs from the bacteria within our mouths fermenting foods and producing acids, whereas the tooth gains minerals from our saliva and fluoride that is present within our mouths.[3] When this balance is skewed due to frequent intake of fermentable carbohydrates, poor oral hygiene and lack of fluoride consumption there is a continuous loss and little gain of minerals over a long period of time, which can ultimately cause what we know as tooth decay.[3] Fissure sealants are a preventive treatment that is part of the minimal intervention dentistry approach to dental care.[4] This approach facilitates prevention and early intervention, in order to prevent or stop the dental caries process before it reaches the ends stage of the disease, which is also known as the "hole" or cavitation of a tooth.[4] Once the tooth is cavitated it requires a dental restoration in order to repair the damage, this emphasizes the importance of prevention in preserving our teeth for a lifetime of chewing.

The aim of fissure sealants is to prevent or arrest the development of dental caries.[5] Preventing tooth decay from the pits and fissures of the teeth is achieved by the fissure sealants blocking these surfaces and therefore stopping food and bacteria from getting stuck in these grooves and fissures.[5] Fissure sealants also provide a smooth surface that is easily accessible for both our natural protective factor, saliva and the toothbrush bristles when cleaning our teeth.[5] Multiple oral health care professionals including a dentist, dental therapist, dental hygienist, an oral health therapist and dental assistants (in some states in the USA) are able to apply dental sealants to teeth.[5]

Dental sealants are a plastic material placed in the pits and fissures (the recesses on the chewing surfaces) of primary (baby) or permanent (adult) molar & premolar teeth at the back of the mouth. These molar teeth are considered the most susceptible teeth to dental caries due to the anatomy of the chewing surfaces of these teeth, which unfortunately inhibits protection from saliva and fluoride and instead favours plaque accumulation.[6]

History

There have been many attempts made within past decades to prevent the development of caries, in particular occlusal caries as it was once generally accepted that pits and fissures of teeth would become infected with bacteria within 10 years of erupting into the mouth.[7][8] G.V. Black, the creator of modern dentistry, informed that more than 40% of caries incidences in permanent teeth occurred in pits and fissures due to being able to retain food and plaque.[9]

One of the first attempts to prevent occlusal caries occurred as early as 1905 by Willoughby D. Miller.[7] Miller, a pioneer of dentistry, was applying silver nitrate to surfaces of teeth, chemically treating the biofilm with its antibacterial functions against both Streptococcus mutans and Actinomyces naeslundii, which are both carious pathogens.[7][8][9][10] Silver nitrate, which was also being practiced by H. Klein and J.W. Knutson in the 1940s, was being used in attempt to prevent and arrest occlusal caries.[9][11]

In 1921, T.P. Hyatt, a pioneer researcher, was the first person to recommend prophylactic odontotomy (preventive operation).[7][9][12] This procedure involved creating Class 1 cavity preps of teeth that were considered at risk of developing occlusal caries, which included all pits and fissures.[7][9][12] The widening of the pits and fissures were then filled with amalgam.[7][9][12]

C.F Bödecker, a dentist and researcher, also made attempts to prevent occlusal caries. Initially, in 1926 Bödecker would use a large round bur to smooth out the fissures. 1929, Bödecker attempted to prevent occlusal caries by cleaning the pit and fissures with an explorer and then sealing the pits and fissures with dental cement, such as oxyphosphate cement.[7] Bödecker then later became an advocator for prophylactic odontotomy procedures (preventive operations).[7][12]

It was in 1955, that M.G. Buonocore gave insight to the benefits of etching enamel with phosphoric acid.[7][8][9] His studies demonstrated that resin could be bonded to enamel through acid etching, increasing adhesion whilst also creating an improved marginal integrity of resin restorative material.[7][9] It was this bonding system that lead to the future successful creation of fissure sealants.[8][12]

In 1966, E.I. Cueto created the first sealant material, which was methyl cyanoacrylate.[7][13] However, this material was susceptible to bacterial breakdown over time, therefore was not an acceptable sealing material.[7] Bunonocore made further advances in 1970 by developing bisphenol-a glycidyl dimethacrylate, which is a viscous resin commonly known as BIS-GMA.[13] This material was used as the basis for many resin-based sealant/composite material developments in dentistry, as it is resistant to bacterial breakdown and forms a steady bond with etched enamel.[7][13]

In 1974, glass ionomer cement fissure seals (GIC) were introduced by J.W. McLean and A.D. Wilson.[13]

Modern sealant materials

Glass ionomer cement - composite resin spectrum of restorative materials used in dentistry. Towards the GIC end of the spectrum, there is increasing fluoride release and increasing acid-base content; towards the composite resin end of the spectrum, there is increasing light cure percentage and increased flexural strength.

Modern dental sealants generally are either resin based or glass ionomer based.[1] Hybrid materials such as polyacid modified resin ("compomer") which lies between these two categories.[1]

Resin based sealants

It is customary to refer to the development of resin based sealants in generations:[13][14]

  1. First generation: set with UV curing.[14] They are no longer marketed.[13]
  2. Second generation: chemical-curing (autopolymerized).[13][14]
  3. Third generation: visible light-cured.[13][14]
  4. Fourth generation: contain fluoride.[13][14]

As part of the wider debate over the safety of bisphenol A (BPA), concerns have been raised over the use of resin based sealants.[13] BPA is a xenoestrogen, i.e. it mimics the relative bioactivity of estrogen, a female sex hormone. Pure BPA is rarely present in dental sealants, however they may contain BPA derivatives.[13] There is very little research about the potential estrogen-like effects of BPA derivatives.[13] A transient presence of BPA in saliva has been reported immediately following placement of some resin based sealants.[13] The longest duration of salivary BPA was 3 hours after placement, so there is little risk of chronic low-dose BPA exposure. The currently available evidence suggests that there is no risk of estrogen-like side effects with resin based sealants.[13] Several national dental organizations have published position statements regarding the safety of resin based dental materials, e.g. the American Dental Association,[nb 1] the Australian Dental Association,[nb 2] the British Dental Association,[nb 3] and the Canadian Dental Association.[nb 4]

Glass ionomer sealants

GIC materials bond both to enamel and dentine after being cleaned with polyacrylic acid conditioner.[7] Some other advantages GIC’s have is that they contain fluoride and are less moisture sensitive, with suggestions being made that despite having poor retention, they may prevent occlusal caries even after the sealant has fallen out due to their ability to release fluoride.[7][13][15]

Effectiveness

Sealants are accepted as an effective preventive method for caries, and as long as the sealant remains adhered to the tooth, caries can be prevented. It is for this reason that sealant success is now measured by the length of time a sealant remains on the tooth, rather than the decay experienced in sealed and unsealed teeth. The ability of a pit and fissure sealant to prevent dental caries is highly dependent on its ability to retain on the tooth surface. The most common reason for sealant failure is salivary contamination during sealing placement. Other factors include clinician inexperience, lack of client co-operation, and less effective sealant material used. [16]

Various factors can help contribute to the retention of fissure sealants. These include:

Longevity

Although sealants do wear naturally and may become damaged over time, they have the potential to remain effective for five years or longer, despite the heavy pressures endured by teeth during chewing each day. Longevity of the dental sealants is also dependent on the type of material used for the fissure sealant.[18] It is not uncommon for fissure sealants to be retained into adulthood. It is believed that bacteria and food particles may eventually become entrapped under the dental sealants, and can thus cause decay in the very teeth intended to be protected. Fissure sealants are inspected during routine dental visits to ensure that they are retained in the fissures of the teeth. One of the major causes to the loss of sealants in the first year is salivary contamination.[17]

On the basis of limited evidence both GIC and resin materials are equally acceptable in caries prevention, however retention rates between GIC and Resin have been shown to differ.[15] Resin has been shown to be the superior product for retention. A 2-year clinical trial comparing GIC and Resin for fissure sealants demonstrated that the GIC had a total loss rate of 31.78%, in contrast to the resin which had a total loss rate of 5.96% The study did acknowledge that GIC had its therapeutic advantages other than retention, this included the benefit of fluoride release and its use on partially erupted teeth.[19] Though GIC has poorer retention rates, the fact that they release active fluoride in the surrounding enamel is very important. They can exert a cariostatic effect and increased release of fluoride, and for these reasons GIC is more of a fluoride vehicle rather than a traditional fissure sealant.[20] All three materials are as effective as each other if the correct techniques are used to complete the procedure.[15]

Indications and contraindications

Indications for the use of dental sealants are individual patients or teeth that are at high risk of dental caries.

This includes patients with:

Contrindications for the use of dental sealants are individual patients or teeth that are at a low risk of dental caries:

This includes patients with:

Clinical procedure

Wikiversity has learning materials related to: Placement of fissure sealants
Dental dam

The exact technique is dependent upon the material used. A rubber dam may be used to prevent saliva from contaminating the intended site to be sealed, although often these are not used, especially for younger children. Moisture control is more of an issue with resin based sealants than with glass ionomer sealants. The surface is cleaned and dried. Resin sealants require an phosphoric acid solution ("etch") to create microscopic porosity, increasing surface area and improving the strength of the bond between the sealant and the tooth surface.[22] The sealant is then applied to the tooth and either set with a curing light or left to dry by itself (depending on the material). Compared to a typical dental filling, where an injection of local anesthetic and use of a dental drill may be involved, fissure sealants are quick and painless.

Notes

  1. ↑ Policy statement of the American Dental Association on Bisphenol A (BPA): "[B]ased on current evidence, the ADA does not believe there is a basis for health concerns relative to BPA exposure from any dental material."
  2. ↑ Policy statement of the Australian Dental Association on BPA (2014)
  3. ↑ Position statement of the British Dental Association on Bisphenol (2005): "More research is needed into the extent of any dental exposure (to bisphenol A) and into the general effects of Bisphenol A exposure, but as the majority of sealants and filling materials only contain Bis-GMA, there will be no resultant oestrogenic effect from using these materials."
  4. ↑ Canadian Dental Association page on frequently asked questions regarding BPA

References

  1. 1 2 3 Hiiri, A; Ahovuo-Saloranta, A; Nordblad, A; Mäkelä, M (17 March 2010). "Pit and fissure sealants versus fluoride varnishes for preventing dental decay in children and adolescents.". The Cochrane database of systematic reviews (3): CD003067. doi:10.1002/14651858.CD003067.pub3. PMID 20238319.
  2. ↑ Scheller-Sheridan, C (8 May 2013). Basic Guide to Dental Materials. John Wiley & Sons. pp. 74–78. ISBN 978-1-118-70831-6.
  3. 1 2 3 Featherstone J.B.D. Dental caries: A dynamic disease process. Australian Dental Journal, 2008.
  4. 1 2 White J.M., & Eakle W.S. Rationale and Treatment Approach in Minimally Invasive Dentistry. Journal of the American Dental Association, 2000.
  5. 1 2 3 4 Fissure sealants. http://www.dentalhealth.ie/download/pdf/fissure_sealant_booklet.pdf. Dental Health. Retrieved 2014-04-11.
  6. ↑ Welbury, R; Raadal, M; Lygidakis, NA; European Academy of Paediatric, Dentistry (September 2004). "EAPD guidelines for the use of pit and fissure sealants." (PDF). European journal of paediatric dentistry : official journal of European Academy of Paediatric Dentistry 5 (3): 179–84. PMID 15471528.
  7. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Avinash, J.; Marya, C.M.; Dhingra, S.; Gupta, P.; Kataria, S.; Meenu; Bhatia, H. P. (2010). "Pit and Fissure Sealants: An Unused Caries Prevention Tool" (PDF). Journal of Oral Health and Community Dentistry 4 (1): 1–6.
  8. 1 2 3 4 Feigal, R. J.; Donly, K. J. (2006). "The Use of Pit and Fissure Sealants". Pediatric Dentistry 28 (2): 143–150.
  9. 1 2 3 4 5 6 7 8 https://scholarworks.iupui.edu/bitstream/handle/1805/2078/view.pdf
  10. ↑ Donovan, T. E.; Anderson, M.; Becker, W.; Cagna, D. R.; Carr, G. B.; Albouy, J.; Metz, J.; Eichmiller, F.; McKee, J. R. (2013). "Annual Review of selected dental literature: Report of the Committee on Scientific Investigation of the American Academy of Restorative Dentistry". The Journal of Prosthetic Dentistry 110 (3): 161–210. doi:10.1016/S0022-3913(13)60358-3.
  11. ↑ Knight, G. M.; McIntyre, J. M.; Craig, G. G.; Zilm, P. S.; Gully, N. J. (2005). "An in vitro model to measure the effect of a silver fluoride and potassium iodine treatment on the permeability of demineralized dentine to streptococcus mutans". Australian Dental Journal 50 (4): 242–5. doi:10.1111/j.1834-7819.2005.tb00367.x.
  12. 1 2 3 4 5 Zero, D. T. (2013). "How the introduction of the acid-etch technique revolutionized dental practice". The Journal of the American Dental Association 144 (9): 990–994. doi:10.14219/jada.archive.2013.0224.
  13. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Ahovuo-Saloranta, A; Forss, H; Walsh, T; Hiiri, A; Nordblad, A; Mäkelä, M; Worthington, HV (28 March 2013). "Sealants for preventing dental decay in the permanent teeth.". The Cochrane database of systematic reviews 3: CD001830. doi:10.1002/14651858.CD001830.pub4. PMID 23543512.
  14. 1 2 3 4 5 Hiremath, SS (15 August 2011). Textbook of Preventive and Community Dentistry. Elsevier India. pp. 428–432. ISBN 978-81-312-2530-1.
  15. 1 2 3 Seth, S (2011). "Glass ionomer cement and resin-based fissure sealants are equally effective in caries prevention" (PDF). JADA 142 (5): 551–552. doi:10.14219/jada.archive.2011.0225.
  16. ↑ Locker, D; Jokovic, A; Kay, EJ (2003). "Prevention. Part 8: The use of pit and fissure sealants in preventing caries in the permanent dentition of children". British Dental Journal 195 (7): 375–8. doi:10.1038/sj.bdj.4810556.
  17. 1 2 Azarpazhooh, A; Main, PA (2008). "Pit and Fissure Sealants in the Prevention of Dental Caries in Children and Adolescents: A Systematic Review". Journal of the Canadian Dental Association 74 (2): 171–7.
  18. ↑ Deery, C (2012). "Pit and fissure sealant retention". Evidence-Based Dentistry 13 (1): 9–10. doi:10.1038/sj.ebd.6400837.
  19. ↑ Forss, H; Saarni, U-M; Seppä, L (1994). "Comparison of glass-ionomer and resin-based fissure sealants: a 2-year clinical trial". Community Dentistry and Oral Epidemiology 22 (1): 21–4. doi:10.1111/j.1600-0528.1994.tb01563.x.
  20. ↑ Beun, S.; Bailly, C.; Devaux, J.; Leloup, G. (2012). "Physical, mechanical and rheological characterisation of resin-based pit and fissure sealants compared to flowable resin composites". Dental Materials 28 (4): 349–359. doi:10.1016/j.dental.2011.11.001.
  21. 1 2 Beauchamp, J. CPW; Crall, J.J.; Donly, K.; Feigal, R.; Gooch, B.; Ismail, A.; Kohn, W.; Siegal, M.; Simonsen, R. (2008). "Evidence-based clinical recommendations for the use of pit-and-fissure sealants: A report of the American Dental Association Council on Scientific Affairs". JADA: 139.
  22. ↑ Frankenberger, R.; Tay, F. R. (2005). "Self-etch vs etch-and-rinse adhesives: Effect of thermo-mechanical fatigue loading on marginal quality of bonded resin composite restorations". Dental Materials 21 (5): 397–412. doi:10.1016/j.dental.2004.07.005.
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