1. Pit and Fissure Sealants Cara Miyasaki-Ching, RDHEF, MS

2. Legal requirements w RDA, RDAEF – DDS decision or supervision w RDH, DDS/DMD – General supervision w Sealant adjustments

3. Requirements - minimum 16 clock hours total w 4 hours of didactic training w 4 hours of laboratory training w 8 hours of clinical training Student shall: w Have current CPR w Take a written exam w RDA or RDA eligible (this includes coronal polish)

4. Requirements - continued Patient requirements w 18 years of age or older w Must be in good health w A minimum of four (4) virgin, non- restored, natural teeth, sufficiently erupted so that a dry field can be maintained. w A minimum of one tooth per quadrant

5. Certification Requirements w Successful completion of written exam w Successful completion of laboratory and clinical portions of the course

6. Pit and fissure sealants w A thin plastic coating placed in the pit and fissures of the teeth to act as a physical barrier to decay

7. Why pit & fissure sealants needed w Bacteria produces acid which causes decay w “demineralization”

8. Pit and fissure sealants w Over 85% of children (5-17 years old) in US have caries in the pits and fissures w Fluoride is least effective on pit and fissures w Only 18% of school-aged children in US have sealants

9. Effectiveness of sealants w 15 year study – 68% of sealed teeth were caries free vs 17% of unsealed control group

10. Other Preventive Programs w Community water fluoridation w School water fluoridation w Fluoridated toothpaste w Fluoride mouthrinse w In-office treatment w 50-60% (18-40%) w 40% w 15-30% w 31% w 26%

11. Preventive Programs as Related to Sealants w Tooth brushing and flossing - mechanical plaque removal w Fluoride – chemical prevention w Dental visits – mechanical plaque removal and chemical prevention

12. Preventive Programs as Related to Sealants - continued Diet w Minimize exposure to cariogenic foods and liquids that have little or no nutritional value w Minimize solid and sticky foods w Minimize slowly dissolving foods

13. History of Sealants w Acrylic polymers introduced to dentistry – 1937 w Composites - 1960 w “Occlusal Sealing” – 1965 w Glass ionomers – 1972

14. Retention of Sealants – 4 year study Fluoride releasing sealant w 91% retention (77% complete & 14% partial) w 10% caries rate Non-fluoride releasing sealant w 95% retention (89% complete & 6% partial) w 10% caries rate

15. Retention of Sealants – 2 year study Fluoride releasing sealant w >90% retention w No caries

16. Sealant retention

17. Sealant Failure w Debris and/or saliva contamination w Air inclusion during manipulation – voids w Manipulating self-cured sealants late in the setting reaction

18. Loss of Sealant w A contaminated site from faulty technique will likely result in complete or partial loss of the sealant within 6-12 months.

19. Cost Factors w Dental Sealants = $25 - $49 per tooth w Amalgam = $75 to $145 per filling w Composite = $150 to $200 for a single surface white composite filling w Medical reimbursement w Insurance reimbursement

20. Preventive Resin Restoration w The preparation of fissures by use of air abrasion, bur or laser followed by filling the prep with a flowable composite.

21. Incipient Caries w Studies have shown that sealants can be placed over incipient caries which arrests the caries process w Most dentists choose to use air abrasion, a bur, or a laser to remove the caries before the sealant is placed

22. Tooth morphology w Pits and fissures

23. Tooth morphology

25. w Why fissures are caries susceptible

26. Selection of teeth Considerations w Patient age w Oral hygiene w Caries risk w Diet w Fluoride history w Tooth type w Morphology

27. Selection of teeth - continued w Frequency of pit & fissure caries w Lower molars – 50% w Upper molars 35-40% w Upper and lower second premolars w Upper laterals and upper first premolars w Upper centrals and lower first premolars

28. Indications w Deep fissures w Incomplete or ill formed pits w Newly erupted teeth w High caries rate w Children w Molars

29. Contraindications w Shallow fissures w Well coalesced pits w Fluoride rich enamel w Low caries rate w Occlusal or proximal caries w Adults

30. Partially erupted teeth? w To seal or not to seal? w Operculum (gum flap) – leaks crevicular fluid

31. Sealant Kits w Cavity Indicators w Drying and/or bonding agent (optional) w Acid etch w Sealant material

32. Acid Etch w Gel w Liquid w 3M Innovation: Adper™ Prompt™ L- Pop™ Self-Etch Adhesive

33. Acid etch w Phosphoric acid 35%-40%-50% w Dissolves organic portion of enamel w “micromechanical retention”

34. Acid etch - continued w Creates more surface area for better adhesion w Also high energy surface

35. Acid etch - Precautions w Avoid contact with adjacent teeth or soft tissues w Can use mylar strips or matrix bands

36. Acid etch –Precautions cont. w Active ingredient – phosphoric acid w Avoid contact with skin, eyes, and clothing. w If skin contact – flush with water w If eye contact – flush immediately with water and seek medical attention w If ingestion- do not induce vomiting. Give large amounts of water or milk. Take an antacid. Call a physician.

37. Acid etch – storage and handling protocol w Protection – protective eyewear, gloves and clothing w Toxicity – mild irritation for skin or ingestion but damage to eye exposure if chronic exposure. w Storage - Store at room temperature. w Handling – Use gloves, protective eyewear and PPE.

38. Acid etch - continued Will an etched tooth be more prone to decay? w Remineralization begins after 24 hours

39. Drying agent (PrimaDry) w Acid etching and Primadry (alcohol based) allows enamel to be easily “wetted”

40. PrimaDry – precautions w Active ingredient – ethyl alcohol w If skin contact – wash with soap and water w If eye contact – flush with lots of water Ingestion- give large amounts of water or milk.

41. PrimaDry – storage and handling protocol w Protection – protective eyewear, gloves and clothing w Toxicity – mild irritation for skin or ingestion but severe irritation for eye exposure w Storage - Store at room temperature. Keep out of heat and/or direct sunlight. w Handling – Use gloves and protective eyewear.

42. Sealant composition w A type of specialized plastic (resin) or glass ionomer material w Matrix w Filler

43. Sealant Types Resin Sealants w (Bis-GMA) Bisphenol A-glycidyl methacrylate resins w Urethane-based resin Glass Ionomer Sealants w Anticariogenic w More viscous, less retention, more brittle and less resistant to occlusal wear

44. Sealant Types w Filled sealants w Unfilled sealants

45. Accepted Sealant Materials ADA Council on Scientific Affairs w 3M ESPE – Clinpro Sealant w Confi-Dental Products Company Confi-Dental Products Company w Dental Technologies Dental Technologies w Dentsply International - FluroShield Dentsply International w Ivoclar Vivadent, Inc. - Helioseal Ivoclar Vivadent, Inc. w Kuraray America Inc. – Teethmate F-1 Kuraray America Inc. w PracticeWares Dental Supply PracticeWares Dental Supply w Pulpdent Corporation Pulpdent Corporation w Southern Dental Industries Southern Dental Industries w Tru-Tain Prime Dental Tru-Tain Prime Dental w Ultradent Products, Inc. - Ultraseal Ultradent Products, Inc. w Zenith/DMG Dental Manufacturing Zenith/DMG Dental Manufacturing

46. Types of curing for sealants Chemical cured – “autopolymerization” w Base and catalyst Monomer & Initiator + Diluted monomer & 5% Organic Amine Accelerator = Sealant Visible light cured – “photopolymerization” w Pre-mixed Dimethacrylate + Diluent + Activator + Light = Sealant

47. Chemical cure sealant materials Advantages w No cure light or risk of eye damage w Can apply sealants to several teeth Disadvantages w Variation in setting time (appx 2 min) w Voids from mixing material w Changes in viscosity over time

48. Light cured sealant materials Advantages w Short setting time (appx 20 seconds) w No mixing required w Won’t set-up – longer working time w Does not get thick Disadvantages w Potential eye damage due to light cure w Additional cost of cure light w Cure time increased with number of teeth sealed w Difficult to manipulate cure light for posterior teeth

49. Sealant Shades w Clear w Tinted w Opaque

50. w Clinpro™ Sealant goes on pink for easy-to-see application, and cures to a natural white. w low viscosity, fluoride- releasing sealant

51. Sealant Material – precautions w Active ingredient – Bis-GMA w Skin contact – wash with soap and water w Eye contact – flush with lots of water & call physician if needed w Ingestion- in large amounts induce vomiting

52. Sealant Material – storage and handling protocol w Protection – protective eyewear, gloves and clothing w Toxicity – mild irritation for skin and eye. Low possiblility of sensitization upon prolonged exposure for the skin. w Storage - Refrigerate when not in use. w Handling – Use gloves, protective eyewear and PPE.

53. Concepts of bonding w Mechanical bonding – interlocking w Chemical bonding – use of adhesive w Physical bonding – attraction of atomic charges

54. Requirements for Adhesion w Clean surface w Good wetting by adhesive w Good adaptation to the substrate w Good interface w Good curing

55. Strength and Viscosity Characteristics Viscosity w The thicker the sealant the less likely to penetrate to depth of fissure Wear of Sealants w Considerations for wear – less filler, more wear and visa versa

56. Curing units w Conventional cure light with halogen bulb = 20 seconds cure for each surface w Plasma arc or laser = 5-10 seconds

57. Assemble armamentarium

58. Assemble sealant kit w Check the operation of the syringe on gauze

59. Armamentarium

60. Curing units w CAUTION – Avoid looking directly at the light

61. Give patient instructions Verbal instructions w 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 w If you have any problems then raise your left hand

62. Give patient instructions Verbal instructions w This won’t hurt but you will need to keep open for a long time and it doesn’t taste very good.

63. Wear personal protective equipment - operator w Gloves w Mask w Safety glasses/visor w Protective clothing w Closed toed shoes

64. Wear personal protective equipment - patient w Safety glasses w Pt. glasses should be tinted when using a curing light (operator/assistant should have tinted glasses on shields)

65. Position patient Mandibular Maxillary

66. Check prescription and teeth w Occlusal surfaces w Buccal and lingual pits on first molars w Lingual pits on upper anterior teeth

67. Suspicious lesions? w Explorer – “a stick” w Caries indicator dye w DIAGNOdent

68. Prepare the tooth w Bristle brush or rubber cup and plain pumice w Dentist can use bur, air abrasion or laser w Sharp explorer to clean out debris w Rinse

69. Prepare the Tooth - continued w air abrasion, bur, prophy jet or laser

70. Position the patient

71. Check occlusion w Avoid placing acid etch and sealant on marked areas from articulator paper

72. Isolate tooth/teeth Treat quadrants separately w To control isolation w To prevent contamination by moisture

73. Isolate tooth/teeth w Rubber dam w Cotton rolls w Cotton roll holders w Dri-angle

74. Dry tooth Test air/water syringe before applying blast of air

75. Apply acid etch w 15-20 seconds w Use blue micro tip or brush tip w Apply only in pit and fissures w For liquid – dab but do not rub w Re-etch 10 seconds if saliva contamination

76. Apply acid etch - continued w 3M Innovation: Adper™ Prompt™ L- Pop™ Self-Etch Adhesive w Etch, prime and bond

77. Apply acid etch w Etch pit and fissures w Extend 1-2 mm beyond pit and fissures w Avoid cusp tips

78. Acid etch - continued Etch longer w Deciduous teeth w Saliva contamination w Air abrasion or prophy jet used w Highly mineralized teeth Do not use explorer

79. Rinse tooth/teeth w Use HVE and a/w syringe w Proper – usually 20 seconds rinse w Avoid saliva contamination w Re-isolate

80. Dry tooth/teeth w Should appear chalky or frosty white if etched w If not, re-etch for another 10 seconds if not contaminated with saliva

81. Apply drying agent (PrimaDry) w Use brush tip w Apply and leave for 5 seconds w Gently blow air to dry w DON’T RINSE

82. Apply bond agent w A bond agent will improve retention

83. Apply sealant material w Most posterior tooth first w Extend 1-2 mm beyond pit and fissures w Gently work into pits and fissures w Avoid lifting off tooth w Don’t overfill w “pop” bubbles in sealant with explorer or brush tip before curing

84. Light cure for 20 seconds w 20 seconds each tooth w Don’t touch tip of cure light to sealant material w Don’t let saliva contaminate the field…..yet Note: sealant will appear shiny/wet

85. Light cure for 20 seconds – air inhibition theory w Top layer of sealant will remain uncured w sealant will appear shiny/wet

86. Check sealed teeth w Use explorer w Tooth should be smooth but not soft w Re-apply sealant, if necessary (Remove uncured sealant with wet cotton roll)

87. Remove isolation materials w Moisten Dri-angle w Rinse the patient’s mouth

88. Check occlusion & contact(s) w Articulating paper w Dental floss w Ask patient how it feels w Dentist can adjust with bullet-shaped finishing bur or polishing stone

89. Give patient instructions w The sealant is hard so you don’t have any restrictions on eating w If it feels “high” after you go home – you can come in to get it adjusted w We will keep checking the sealant at subsequent appointments (if using unfilled corposite sealant the bite will self adjust in 2-3 days)

90. 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.

91. Infection control w Disinfect unit w Disinfect sealant syringes w Throw away brush tips used in patient’s mouth w Sharp tips need to be placed with sharps container

92. Common Problems Re-etch w Improperly etched surface – doesn’t appear frosty and chalky white w Dentin etching – need to dissolve smear layer w Contamination of application site – saliva w Non-adherence of sealant material

93. Failure of sealants w Main cause – moisture contamination w Maxillary and mandibular 2 nd molars w Early loss means less retention of the resin

94. Sealing over caries w For incipient caries – risk of progression is very small

95. Risks associated with sealants w No carcinogens or toxic materials w Have xenoestrogens – concentrations too low w Potential chemical burns from phosphoric acid w Occlusal trauma w Danger from cure light

96. Sealant maintenance w Loss of all or part of the sealant w Staining at edges w Discoloration underneath sealant

97. Repair of sealant Reapply if totally lost Repair partial loss w Roughen with diamond stone w Re-etch 20 seconds w Reapply sealant

98. Finished!