WRITTEN BY Sebastiana Gagliano Springmann, DDS
Pit-and-fissure sealants have proven to be integral to prevention. The organic polymer (resin) flows into a pit or fissure and bonds to the enamel surface. It seals as deeply as possible and prevents bacteria from collecting and creating caries. Even when sealant material is worn or cracked on the surface, the deepest aspects of the pit or fissures can provide continued protection. Sealants are esthetic, noninvasive, and performed without anesthetic.
Their success depends on adhering firmly to the enamel surfaces and isolating pits and fissures from the rest of the oral environment. Pits and fissures are fossi and grooves that failed to fuse during development.1 The narrow width and uneven depth make them a haven for bacteria. Saliva, which cleans food from the mouth, cannot clean pits and fissures in molars. Sealants prevent bacteria and dietary carbohydrates from creating the acid conditions that result in caries. Conventional sealants are noninvasive, and they maintain tooth integrity while providing acceptable resolutions of the carious process.
The first clinical sealant trial was reported in 1965. The first provisional acceptance of a marketed sealant by the American Dental Association was granted in the early 1970s.2
Prevention is better than restorative treatment, and sealants are one of the easiest, most cost-effective ways to prevent pit-and-fissure decay.
To place or not to place
Sealants are used primarily on children, but adults with appropriate indications can benefit. Patient selection and application techniques are important when recommending sealants.
At least 25 percent of my patients are children as young as 2, and we treat younger ones for emergencies. Children and teenagers are obvious candidates for sealants. We place them on all pit-and-fissure surfaces on first and second molars. Premolars with particularly deep pits also benefit, but parents are often reluctant when insurance doesn’t cover it.
Anyone with deep pits and fissures can benefit. Adults at risk for caries can too, but some do not have them applied because of lack of reimbursement. Adults should consider when they are at risk for decay from medication-induced xerostomia, changes in diet, changes in health and medication, lack of access to fluoridated water, or lack of use of fluoridated water (often from drinking bottled water). These factors may increase rate of decay. We suggest patients drink tap water because we have fluoridated water. In addition, we offer fluoride rinses or gels to patients who could benefit from more fluoride.
In our office, the only time a sealant would be contraindicated is if active decay extends into the dentin. Even when decay is sealed inadvertently, according to studies published in the Journal of the American Dental Association, caries will not progress beneath a properly placed sealant, and a lesion inadvertently sealed will arrest.3, 4
Materials and techniques
Since sealants were introduced more than 25 years ago, new materials have been developed, and many aspects of sealant application have been modified. Sealants are generally either resin-based or glass ionomers. Resin-based sealants, with characteristics of flow ability and retentiveness, work well for many years when placed properly. Their limitation is that the tooth must be properly isolated and contamination must be avoided throughout the procedure as it can result in failure. Glass ionomers can be considered, for example, for primary molars having deeply pitted or fissured surfaces that are difficult to isolate. For two years, we’ve been using only ClinproTM Sealant (3M ESPE).
Using an explorer, visual examination, and radiographs to determine caries also determines the need for a sealant. If a tooth is appropriate for a sealant, one must decide on a resin-based or glass ionomer sealant.
If using a resin-based sealant, isolate the tooth and avoid contamination of the surface during the procedure. The traditional technique for sealant placement is as follows:
1 Clean, isolate, and dry the selected teeth
2 Etch with phosphoric acid for 15 seconds
3 Rinse thoroughly
4 Dry tooth until frosty
5 If frosty appearance is not obtained, apply etchant again, rinse, and dry
6 Apply sealant
7 Light cure
8 Check for coverage
9 Wipe off air-inhibited layer
An alternative to the traditional technique is using a self-etching adhesive instead of phosphoric acid. When considering this treatment, it is important to know the effectiveness of the adhesive bond to uncut enamel. AdperTM PromptTM Adhesive from 3M ESPE is unique in that its acidic nature provides a high bond to both cut and uncut enamel surfaces without having to first etch the enamel. It’s ideal for sealant placement. With the current use of the Adper Prompt Self-Etch Adhesive/Clinpro sealant technique, sealant placements in our office are easier, faster, and more reliable. Since January 2005, we have placed 391 sealants on 115 patients with no issues.
This alternative sealant technique, which does not require a rinsing step, is as follows:
1 Clean/isolate/dry selected teeth
2 Apply Adper Prompt Self-Etch Adhesive for 15 seconds with a scrubbing motion
3 Gently but thoroughly dry the adhesive for 10 seconds; the tooth surface will appear glossy, but not moist
4 Apply sealant
5 Light cure
6 Check for coverage
7 Wipe off air-inhibited layer
This technique saves time, lowers the complexity of the procedure by eliminating the rinsing step, and decreases the challenge of patient management. In addition, studies have shown that when using the Adper Prompt Self-Etch Adhesive, there is significantly less microleakage compared with conditioning with phosphoric acid before sealant application.1
Educate, educate, educate
Patients must be educated that sealants are part of a total preventive program and are not substitutes for other preventive measures. In addition, sealants might be retained for many years. If deficiencies arise and are noted during recare appointments, they must be corrected.
Sealants are one of the best preventive measures we can offer our patients and are cost-effective when placed by a dental auxiliary.
If sealants are charged at approximately $45 per tooth, and four teeth can be sealed in 30 minutes, this yields a production rate of $360 per hour. Thirty-six states including Virginia, where I practice, offer sealant placement as an expanded function for dental assistants.
With proper placement and maintenance, a sealant has proven longevity and will protect the caries-susceptible pits and fissures of the tooth from decay. With professional dental care, fluoride therapies, patient compliance with plaque removal, and sealant placement, we have the tools to help our patients keep their teeth for a lifetime. ■ References available on request.
Sebastiana Gagliano Springmann, DDS
Dr. Springmann has practiced in Williamsburg, Va., since 1992. She attended New York University, The College of William and Mary, and The Medical College of Virginia. Reach her at (757) 259-0741 or [email protected].