Treating Pits and Fissures Among Children
Bioactive resin sealants facilitate long-term strength and remineralization
Shalom Mehler, DMD
Despite the fact that pit and fissure sealants have been a part of our armamentarium for almost 50 years, have a proven track record of safety and efficacy, and are recommended for use by the American Dental Association (ADA) and the American Academy of Pediatric Dentistry (AAPD), the prevalence of sealants used in the United States for children aged 6 to 11 years is just 43.2%.1,2 In addition, although recent data indicates that the number of untreated caries among US children remains below 20% for children aged 5 to 19 years, it is clear that preventive measures, including dietary sugar control, topical fluoride treatments, and pit and fissure sealants, are underutilized.3,4 The US Centers for Disease Control and Prevention (CDC) estimates that the use of school-based programs to apply sealants to the nearly seven million low-income children who do not have them could prevent more than three million carious lesions and save up to $300 million in dental treatment costs.5
According to the ADA, caries is "a disease caused by an ecological shift in the composition and activity of the bacterial biofilm when exposed over time to fermentable carbohydrates, leading to a break in the balance between demineralization and remineralization."2 Because the anatomy of pits and fissures can make removal of the plaque biofilm difficult, sealants can help protect against dental caries by preventing cariogenic bacteria from accessing hard to clean areas and preventing existing bacteria from accessing fermentable carbohydrates and metabolizing these to produce the acid that demineralizes tooth structure.
In 2002, the AAPD noted that the profession must be alert to new preventive methods that are effective against pit and fissure caries, which may include changes in dental materials or technology.6 Fourteen years later, in 2016, the ADA and the AAPD issued joint recommendations supporting the use of pit and fissure sealants to treat primary and permanent molars with sound or non-cavitated carious occlusal surfaces among children and adolescents.2
Historically, dental sealant materials have been based on either glass ionomer or resin technology. Both sealant materials offer advantages and have disadvantages; however, the success of pit and fissure sealants largely depends on their long-term retention and durability. Despite the fluoride release created by glass-ionomer sealants, their lower tensile strength and wear resistance can make them prone to premature dislodgment. Therefore, they may be more appropriate as interim sealants for newly erupting teeth. By comparison, resin-based sealants offer higher strength, improved wear resistance, and lower solubility in the oral environment. Because of these factors, the retention achieved by resin-based sealants can be superior to that of glass-ionomer sealants, especially in teeth undergoing mastication.6
Today, newer resin-based sealants are available with delivery systems containing fluoride, calcium, and/or phosphate that are designed to harness the strengths of resin sealants (ie, retention and durability) while providing the potential for remineralization that was previously impossible with resin. All dental resin composites are porous to some degree, including those that release fluoride or other substances. Furthermore, the porosity of the resin material (ie, substrate) allows ions to move through it in both directions: from the inside out, to increase the concentration at the tooth-material interface, and from the outside in, to replenish ions from external sources (eg, saliva and toothpastes). Clinically, for a pit and fissure sealant to be useful, it must be retentive and durable, but chairside, it must also be easy to use and manipulate.
A 12-year-old male patient presented to the office with pits and fissures on tooth No. 19 (Figure 1). The tooth was fully erupted with no detectable decay. A treatment plan involving the use of pit and fissure sealant was recommended, and the patient's parent consented to the treatment.
Prior to the sealing procedure, the tooth was cleaned with pumice using a prophy angle (2pro® Disposable Prophy Angle, Premier Dental Products) on a slow-speed handpiece. For this case, coarse pumice was used to clean the tooth using the prophy cup, then the cup was removed, and the exposed soft tip was used to clean in the grooves (Figure 2 and Figure 3). Alternatively, the grooves of the teeth can be debrided using an air abrasion system, a small fissure preparation bur, or simply a toothbrush. Next, an etchant (Premier® Etch, Premier Dental Products) was applied to the occlusal surface, allowed to react for 20 seconds, and then thoroughly rinsed away with water and dried (Figure 4 through Figure 6). Following rinsing and drying, isolation of the area was accomplished using cotton rolls.
Using a syringe and cannula tip, a sealant in natural white shade (BioCoat™ Bioactive Resin Pit and Fissure Sealant, Premier Dental Products) was slowly introduced into the pits and fissures of tooth No. 19. Care was taken to prevent the sealant from flowing beyond the etched area of the tooth. Once flowed, an explorer was used to facilitate extension into all of the grooves and ensure ample material coverage with no bubbles. This sealant was chosen because it offers the benefits of SmartCap™ Technology, which utilizes microcapsules averaging 1 to 2 μm in in size, to store and deliver active ingredients (ie, fluoride, calcium, phosphate) that can contribute to remineralization. Unlike the delivery systems of other sealants, SmartCap Technology, in effect, creates an intracapsular reservoir for this ion-rich aqueous solution without weakening the resin structure of the sealant.
Next, the sealant was light cured at an intensity of 600 mW/cm2 for 20 seconds. A proper light-curing technique includes keeping the light guide as close to the tooth as possible without actually touching the sealant. After light curing, the tooth was inspected to verify complete coverage of the pits and fissures and then wiped with a cotton pledget to remove the air-inhibited layer. The patient was asked to bite down and report any interference with proper occlusion or discomfort. In this case, no occlusal adjustment was required, and the patient was dismissed with a properly placed sealant on tooth No. 19 (Figure 7).
About the Author
Shalom Mehler, DMD
Teaneck, New Jersey
1. US Centers for Disease Control and Prevention. Vital Signs: Dental Sealant Use and Untreated Tooth Decay Among US School-Aged Children. CDC Website. https://www.cdc.gov/mmwr/volumes/65/wr/mm6541e1.htm. Published October 18, 2016. Accessed March 28, 2018.
2. Wright JT, Crall JJ, Fontana M, et al. Evidence-based clinical practice guideline for the use of pit-and-fissure sealants. J Am Dent Assoc. 2016;147(8):672-682.
3. Naaman R, El-Housseiny AA, Alamoudi N. The use of pit and fissure sealants-a literature review. Dent J (Basel). 2017;5(4):34.
4. US Centers for Disease Control and Prevention. National Center for Health Statistics. Health, United States, 2016: With Chartbook on Long-term Trends in Health. CDC Website. https://www.cdc.gov/nchs/data/hus/hus16.pdf. Published 2017. Accessed April 17, 2018.
5. US Centers for Disease Control and Prevention. Dental Sealants. CDC Website. https://www.cdc.gov/oralhealth/dental_sealant_program/
index.htm. Updated March 16, 2018. Accessed April 17, 2018.
6. Crall JJ, Donly KJ. Dental sealants guidelines development: 2002-2014. Pediatr Dent. 2015;37(2):
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