Management of Deep Pits and Fissures

Objectives Students should be able to Explain concept of pit fissure sealant and Preventive resin restoration (PRR) Discuss advantages, disadvantages and indications for pit and fissure sealant Discuss advantages, disadvantages and indications for Preventive resin restoration Describe the procedures of Pit and fissure sealant and Preventive resin restoration

Cariology Dental caries is an infectious microbiological disease of teeth that results in localized dissolution and destruction of the calcified tissues. S. Mutans have been demonstrated to have significant potential to cause caries

Host caries Microflora Substrate

Pit & fissure: highest prevalence of all dental caries narrow opening, almost impossible to clean Plaque accumulation (bacteria harbor) Fluoride is less effective to prevent pit & fissure caries

Pit & fissure: highest prevalence of all dental caries narrow opening, almost impossible to clean Plaque accumulation (bacteria harbor) Fluoride is less effective to prevent pit & fissure caries

Management of deep fissure Prophylactic odontomy Fissure eradication Enameloplasty Fluoride Sealant

Management of deep fissure Prophylactic odontomy (Hyatt 1923) Eliminating all susceptible fissures by cutting a shallow, minimal width class I cavity in enamel. Then the cavity is filled with amalgam Destructive, committed to a restoration

Management of deep fissure Fissure eradication (Bodecker 1929) Fissures reshaped by reducing the steep cuspal inclines so that the occlusal surface is more readily cleansed by the patient Destructive

Management of deep fissure Enameloplasty Grinding away enamel on developmental deep pit and fissure to create a smooth, saucer-shaped surface which is self cleansing or easily cleaned

Management of deep fissure Fluoride Systemic/topical F¯ most effective in preventing smooth surface caries but least effective in occlusal surface It is speculated that neither stannous nor acidulated fluoride is able to impregnate the enamel at the depths of the fissures

Pit and fissure sealant

Management of deep fissure Pit fissure sealing The idea is to form a barrier that protects pits and fissures against bacteria and fermentable foods like sugars and starches, and thereby helps to prevent decay from starting deep within these fissures

Pit & fissure sealants were first introduced in 1967 by Cueto & Buonocore Enamel is etched and bonded with resin Fissure is sealed and protected from the ingress of plaque, microflora, and oral fluid.

Bacteria remaining in sealed fissures? Studies have shown a decrease in numbers of microorganisms in lesions under intact sealants, and caries progression appeared negligible Jenson & Handelman 1980, Handelman & Leverett 1985, Martz-Hfairhurst et al 1986

Advantages & Disadvantages Caries is prevented as long as fissures remain completely sealed If there is lost or leakage of the sealants, the tooth is once again at risk to caries Needs periodic evaluation

Indications Newly erupted posterior teeth with complicated fissures High caries risk patient with deep pits & fissures Incipient caries where caries is limited to enamel Bite wing radiographs should be taken to ensure that caries does not extend to the DEJ and proximal surfaces

Contraindications When adequate isolation cannot be achieved Where definite occlusal decay is present When proximal decay is present On hypoplastic teeth In uncooperative patients

Ideal Properties of fissure sealant Should seal the pits and fissures against every penetration by oral flora Adhere to enamel (high retention rate) Should have a cariostatic action (F release) Resistant to oral fluid and diet (acid, alcohol, etc) Low viscosity

Ideal Properties of fissure sealant Adequate mechanical properties on setting (strength, abrasive resistance) Simple to use Non toxic Should be detectable Have short setting/polymerization time

Materials of choice Resin-based fissure sealants Compomer Unfilled resin (bis-GMA) Lightly filled resin Fluoride containing resin Compomer Glass ionomer cements

Resin-based sealants Resin sealant : Diluents (TEGDMA) BIS-GMA Polyurethanes Cyanoacrylate Diluents (TEGDMA)

Choice of materials (resin-based sealant) Light cured or Chemical cured Chemical cured is no longer available Unfilled or slightly filled resin filler particles are added to improve abrasive resistance

Choice of materials (resin-based sealant) Translucent or opaque (or coloured)

Compomer sealant Composition Polymerisable Strontium-alumino-fluoro-silicate glass Modified carboxylic acid Phosphate-modified monomers No laboratory or clinical date available

Glass ionomer sealant Powder-liquid form Chemical cured Finer filler particles

Effectiveness Retention rate & caries reduction Researches showed that sealant efficacy is directly related to sealant retention Sealant placement also leads to a reduced prevalence of restorations having to be placed later on.

Dennison & others JADA 2000 A retrospective study of 5,203 children 6.5% 6.6% 6.2% Graph shows Incidence of restoration placement on 1st molars with and without sealants.

Dennison & others JADA 2000 A retrospective study of 5,203 children Restoration Incidence (%) 10.4% 10.1% 8.7% Graph shows Incidence of restoration placement on 2st molars with and without sealants.

Effectiveness Going et al 1977 reported caries prevention effectiveness (10 years) premolar: 84% molar : 30% Mertz-Fairhurst et al 1984 (7 years) caries reduction effectiveness 55% Romcke et al 1990 (10 years) 3% of the sealant had been replaced with restorations due to decay Wendt &others 2001 reported 65% complete retention of sealant on 1st molar after 20 years with 13% of caries/restorations placed 65% complete retention on 2nd molar with 5% caries/restorations placed

Effectiveness of GIC sealant Retention rate & effectiveness comparable to resin sealant?

Armamentarium Rubber dam armamentarium Mouth mirror, straight probe, cotton forceps Miller’s forceps Prophy brush Slow speed ¼ round bur

Procedures Give a local anesthetic if necessary Isolate the tooth Remove calculus or debris

Procedures If enamel caries is present, use ¼ round bur to widen the fissure and remove caries Clean the pit and fissure surfaces with prophy brush and pumice

Procedures Etch the surface with acid etchant Wash and dry

Procedures Apply sealant Light cure

Procedures Check occlusion

Procedures Adjust occlusion using white stone or finishing bur

Sealant failure Usually occurs at enamel-resin interface Mostly caused by saliva or moisture contamination during application

Preventive Resin Restoration Treatment of small carious lesions where caries is removed and restored with composite resin.Fissure sealant is then applied to the surrounding pits and fissures

Preventive Resin Restoration Introduced by Simonsen and Stallard in 1977 Minimally invasive G.V. Black “extension for prevention” is no longer practised Small carious lesions within pits and fissures were removed and restored with composite resin while the remaining healthy fissures were sealed with a pit and fissure sealant

Advantages Conservative approach Minimum intervention -conserve more tooth structure More aesthetic compared to amalgam

Disadvantages Needs absolute moisture control Bonding procedures are very technique sensitive More time consuming Failure to proper bonding will lead to leakage and recurrent caries

Indications Small occlusal caries with a deep pit and fissure An opaque, chalky or brown/black lesions along the pits and fissure, suggestive of caries

Type I Caries is very minimal and limited in enamel Remove caries with 1/4 round bur Sealant is then applied Pit & fissure Sealant

Type II After caries removal with ¼ or ½ round bur, the preparation is limited in enamel but is greater than 1 mm in cross section Posterior composite placement in the preparation Sealant applied over composite restoration and fissures

Type III Caries extends into dentin Remove caries with suitable size round bur Glass ionomer base placed over dentin. CaOH2 may be required if the cavity is deep Restore the cavity with Posterior composite resin Seal the entire surface with sealant

Clinical Procedures Local anesthetic if necessary Apply rubber dam Clean the tooth Cavity preparation Use a small round bur to widen the fissure

Clinical Procedures If caries is limited in enamel sealant If caries extend to dentin, use a pear-shape bur (No 330) to gain access Remove caries using suitable round bur with slow speed hand piece

Clinical Procedures Place liner or base in deep cavity (GIC) Etch the cavity and the rest of occlusal surface

Clinical Procedures Wash and dry Bonding Apply primer and adhesive over the cavity (follow manufacturer’s instruction)

Clinical Procedures Composite resin placement Underfill the cavity Light cure

Clinical Procedures Seal the entire surface Check occlusion

Recall Maintenance and periodic review is essential Replacement of sealant should be done if marginal debonding or sealant loss is observed