1. Management of
Deep Pits and Fissures

2. 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

3. 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

4. Host
caries
Microflora
Substrate

5. 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

6. 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

7. Management of deep fissure
Prophylactic odontomy
Fissure eradication
Enameloplasty
Fluoride
Sealant

8. 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

9. 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

10. 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

11. 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

12. Pit and fissure sealant

13. 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

14. 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.

15. 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

16. 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

17. 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

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

19. 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

20. 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

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

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

23. 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

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

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

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

27. 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.

28. 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.

29. 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.

30. 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

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

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

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

34. 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

35. Procedures
Etch the surface with acid etchant
Wash and dry

36. Procedures
Apply sealant
Light cure

37. Procedures
Check occlusion

38. Procedures
Adjust occlusion using white stone or finishing bur

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

40. 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

41. 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

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

43. 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

44. 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

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

46. 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

47. 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

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

50. 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

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

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

53. Clinical Procedures Composite resin placement Underfill the cavity
Light cure

54. Clinical Procedures
Seal the entire surface
Check occlusion

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