2. Legal requirements
RDA, RDAEF – DDS decision or supervision
RDH, DDS/DMD – General supervision
Sealant adjustments
3. Requirements - minimum
16 clock hours total Student shall:
4 hours of didactic Have current CPR
training Take a written exam
4 hours of laboratory RDA or RDA eligible
training (this includes coronal
8 hours of clinical polish)
training
4. Requirements - continued
Patient requirements
18 years of age or older
Must be in good health
A minimum of four (4) virgin, non-restored,
natural teeth, sufficiently erupted so that a
dry field can be maintained.
A minimum of one tooth per quadrant
8. Pit and fissure sealants
Over 85% of children (5-17 years old) in US
have caries in the pits and fissures
Fluoride is least effective on pit and fissures
Only 18% of school-aged children in US have
sealants
9. Effectiveness of sealants
15 year study – 68%
of sealed teeth were
caries free vs 17% of
unsealed control
group
10. Other Preventive Programs
Community water
fluoridation 50-60% (18-40%)
School water
fluoridation 40%
Fluoridated toothpaste 15-30%
Fluoride mouthrinse 31%
In-office treatment 26%
11. Preventive Programs as Related to
Sealants
Tooth brushing and flossing - mechanical
plaque removal
Fluoride – chemical prevention
Dental visits – mechanical plaque removal
and chemical prevention
12. Preventive Programs as Related to
Sealants - continued
Diet
Minimize exposure to cariogenic foods and
liquids that have little or no nutritional
value
Minimize solid and sticky foods
Minimize slowly dissolving foods
13. History of Sealants
Acrylic polymers introduced to dentistry –
1937
Composites - 1960
“Occlusal Sealing” – 1965
Glass ionomers – 1972
17. Sealant Failure
Debris and/or saliva contamination
Air inclusion during manipulation – voids
Manipulating self-cured sealants late in the
setting reaction
18. Loss of Sealant
A contaminated site from faulty technique
will likely result in complete or partial loss
of the sealant within 6-12 months.
19. Cost Factors
Dental Sealants = $25 - $49 per tooth
Amalgam = $75 to $145 per filling
Composite = $150 to $200 for a single surface
white composite filling
Medical reimbursement
Insurance reimbursement
20. Preventive Resin Restoration
The preparation
of fissures by use
of air abrasion,
bur or laser
followed by
filling the prep
with a flowable
composite.
21. Incipient Caries
Studies have shown that sealants can be
placed over incipient caries which arrests
the caries process
Most dentists choose to use air abrasion, a
bur, or a laser to remove the caries before
the sealant is placed
27. Selection of teeth - continued
Frequency of pit & fissure caries
Lower molars – 50%
Upper molars 35-40%
Upper and lower second premolars
Upper laterals and upper first premolars
Upper centrals and lower first premolars
28. Indications
Deep fissures
Incomplete or ill formed pits
Newly erupted teeth
High caries rate
Children
Molars
34. Acid etch - continued
Creates more
surface area for
better adhesion
Also high
energy surface
35. Acid etch - Precautions
Avoid contact with
adjacent teeth or soft
tissues
Can use mylar strips
or matrix bands
36. Acid etch –Precautions cont.
Active ingredient – phosphoric acid
Avoid contact with skin, eyes, and clothing.
If skin contact – flush with water
If eye contact – flush immediately with water
and seek medical attention
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
Protection – protective eyewear, gloves and
clothing
Toxicity – mild irritation for skin or ingestion
but damage to eye exposure if chronic
exposure.
Storage - Store at room temperature.
Handling – Use gloves, protective eyewear and
PPE.
38. Acid etch - continued
Will an etched tooth be
more prone to decay?
Remineralization
begins after 24 hours
39. Drying agent (PrimaDry)
Acid etching and
Primadry (alcohol
based) allows enamel
to be easily “wetted”
40. PrimaDry – precautions
Active ingredient – ethyl alcohol
If skin contact – wash with soap and water
If eye contact – flush with lots of water
Ingestion- give large amounts of water or milk.
41. PrimaDry – storage and handling
protocol
Protection – protective eyewear, gloves and
clothing
Toxicity – mild irritation for skin or ingestion
but severe irritation for eye exposure
Storage - Store at room temperature. Keep out
of heat and/or direct sunlight.
Handling – Use gloves and protective eyewear.
42. Sealant composition
A type of
specialized plastic
(resin) or glass
ionomer material
Matrix
Filler
43. Sealant Types
Resin Sealants Glass Ionomer Sealants
(Bis-GMA) Bisphenol Anticariogenic
A-glycidyl More viscous, less
methacrylate resins retention, more brittle
Urethane-based resin and less resistant to
occlusal wear
45. Accepted Sealant Materials
ADA Council on Scientific Affairs
3M ESPE – Clinpro Sealant
Confi-Dental Products Company
Dental Technologies
Dentsply International - FluroShield
Ivoclar Vivadent, Inc. - Helioseal
Kuraray America Inc. – Teethmate F-1
PracticeWares Dental Supply
Pulpdent Corporation
Southern Dental Industries
Tru-Tain Prime Dental
Ultradent Products, Inc. - Ultraseal
Zenith/DMG Dental Manufacturing
46. Types of curing for sealants
Chemical cured – “autopolymerization”
Base and catalyst
Monomer & Initiator + Diluted monomer & 5% Organic
Amine Accelerator = Sealant
Visible light cured – “photopolymerization”
Pre-mixed
Dimethacrylate + Diluent + Activator + Light = Sealant
47. Chemical cure sealant materials
Advantages
No cure light or risk of eye damage
Can apply sealants to several teeth
Disadvantages
Variation in setting time (appx 2 min)
Voids from mixing material
Changes in viscosity over time
48. Light cured sealant materials
Advantages
Short setting time (appx 20 seconds)
No mixing required
Won’t set-up – longer working time
Does not get thick
Disadvantages
Potential eye damage due to light cure
Additional cost of cure light
Cure time increased with number of teeth sealed
Difficult to manipulate cure light for posterior teeth
50. Clinpro™ Sealant goes
on pink for easy-to-see
application, and cures to
a natural white.
low viscosity, fluoride-
releasing sealant
51. Sealant Material – precautions
Active ingredient – Bis-GMA
Skin contact – wash with soap and water
Eye contact – flush with lots of water & call
physician if needed
Ingestion- in large amounts induce vomiting
52. Sealant Material – storage and
handling protocol
Protection – protective eyewear, gloves and
clothing
Toxicity – mild irritation for skin and eye. Low
possiblility of sensitization upon prolonged
exposure for the skin.
Storage - Refrigerate when not in use.
Handling – Use gloves, protective eyewear and
PPE.
53. Concepts of bonding
Mechanical bonding – interlocking
Chemical bonding – use of adhesive
Physical bonding – attraction of atomic
charges
54. Requirements for Adhesion
Clean surface
Good wetting by adhesive
Good adaptation to the substrate
Good interface
Good curing
55. Strength and Viscosity
Characteristics
Viscosity
The thicker the sealant the
less likely to penetrate to
depth of fissure
Wear of Sealants
Considerations for wear –
less filler, more wear and visa
versa
56. Curing units
Conventional cure light with halogen bulb =
20 seconds cure for each surface
Plasma arc or laser = 5-10 seconds
61. Give patient instructions
Verbal instructions
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
If you have any
problems then raise
your left hand
62. Give patient instructions
Verbal instructions
This won’t hurt but
you will need to keep
open for a long time
and it doesn’t taste
very good.
64. Wear personal protective
equipment - patient
Safety glasses
Pt. glasses should be
tinted when using a
curing light
(operator/assistant
should have tinted
glasses on shields)
75. Apply acid etch
15-20 seconds
Use blue micro tip or
brush tip
Apply only in pit and
fissures
For liquid – dab but do
not rub
Re-etch 10 seconds if
saliva contamination
76. Apply acid etch - continued
3M Innovation:
Adper™
Prompt™ L-
Pop™ Self-Etch
Adhesive
Etch, prime and
bond
77. Apply acid etch
Etch pit and fissures
Extend 1-2 mm beyond
pit and fissures
Avoid cusp tips
78. Acid etch - continued
Etch longer
Deciduous teeth
Saliva contamination
Air abrasion or prophy
jet used
Highly mineralized
teeth
Do not use explorer
79. Rinse tooth/teeth
Use HVE and a/w
syringe
Proper – usually
20 seconds rinse
Avoid saliva
contamination
Re-isolate
80. Dry tooth/teeth
Should appear chalky
or frosty white if
etched
If not, re-etch for
another 10 seconds if
not contaminated
with saliva
81. Apply drying agent (PrimaDry)
Use brush tip
Apply and leave for 5
seconds
Gently blow air to dry
DON’T RINSE
83. Apply sealant material
Most posterior tooth first
Extend 1-2 mm beyond pit
and fissures
Gently work into pits and
fissures
Avoid lifting off tooth
Don’t overfill
“pop” bubbles in sealant
with explorer or brush tip
before curing
84. Light cure for 20 seconds
20 seconds each tooth
Don’t touch tip of cure
light to sealant
material
Don’t let saliva
contaminate the
field…..yet
Note: sealant will appear
shiny/wet
85. Light cure for 20 seconds – air
inhibition theory
Top layer of sealant
will remain uncured
sealant will appear
shiny/wet
86. Check sealed teeth
Use explorer
Tooth should be
smooth but not soft
Re-apply sealant, if
necessary
(Remove uncured
sealant with wet
cotton roll)
88. Check occlusion & contact(s)
Articulating paper
Dental floss
Ask patient how it
feels
Dentist can adjust with
bullet-shaped finishing
bur or polishing stone
89. Give patient instructions
The sealant is hard so you don’t have any
restrictions on eating
If it feels “high” after you go home – you
can come in to get it adjusted
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
Disinfect unit
Disinfect sealant
syringes
Throw away brush
tips used in patient’s
mouth
Sharp tips need to be
placed with sharps
container
92. Common Problems
Re-etch
Improperly etched surface – doesn’t appear
frosty and chalky white
Dentin etching – need to dissolve smear
layer
Contamination of application site – saliva
Non-adherence of sealant material
93. Failure of sealants
Main cause – moisture
contamination
Maxillary and
mandibular 2nd molars
Early loss means less
retention of the resin
94. Sealing over caries
For incipient caries –
risk of progression is
very small
95. Risks associated with sealants
No carcinogens or toxic materials
Have xenoestrogens – concentrations too low
Potential chemical burns from phosphoric acid
Occlusal trauma
Danger from cure light
96. Sealant maintenance
Loss of all or part of
the sealant
Staining at edges
Discoloration
underneath sealant
97. Repair of sealant
Reapply if totally lost
Repair partial loss
Roughen with
diamond stone
Re-etch 20 seconds
Reapply sealant
Over 85% of children (5-17 years old) in US have caries in the pits and fissures - these children are mostly from low-income families and other vulnerable populations
Initial studies of community water fluoridation demonstrated that reductions in childhood dental caries attributable to fluoridation were approximately 50%--60% ( 94--97 ). More recent estimates are lower --- 18%--40% ( 98,99 ). This decrease in attributable benefit is likely caused by the increasing use of fluoride from other sources, with the widespread use of fluoride toothpaste probably the most important. The diffusion or "halo" effect of beverages and food processed in fluoridated areas but consumed in nonfluoridated areas also indirectly spreads some benefit of fluoridated water to nonfluoridated communities. This effect lessens the differences in caries experience among communities ( 100 ). Studies of the effects of school water fluoridation in the United States reported that this practice reduced caries among schoolchildren by approximately 40% ( 118--122 ). A more recent study indicated that this effect might no longer be as pronounced ( 123 ). Studies of 2--3 years duration have reported that fluoride toothpaste reduces caries experience among children by a median of 15%--30% ( 139--148 ). This reduction is modest compared with the effect of water fluoridation, but water fluoridation studies usually measured lifetime --- rather than a few years' --- exposure. Regular lifetime use of fluoride toothpaste likely provides ongoing benefits that might approach those of fluoridated water. Combined use of fluoride toothpaste and fluoridated water offers protection above either used alone ( 99,149,150 ). Studies indicating that fluoride mouthrinse reduces caries experience among schoolchildren date mostly from the 1970s and early 1980s ( 184--191 ). In one review, the average caries reduction in nonfluoridated communities attributable to fluoride mouthrinse was 31% ( 191 ). Two studies reported benefits of fluoride mouthrinse approximately 2.5 and 7 years after completion of school-based mouthrinsing programs ( 192,193 ), but a more recent study did not find such benefits 4 years after completion of a mouthrinsing program ( 194 ). The National Preventive Dentistry Demonstration Program (NPDDP), a large project conducted in 10 U.S. cities during 1976--1981 to compare the cost and effectiveness of combinations of caries-prevention procedures, reported that fluoride mouthrinse had little effect among schoolchildren, either among first-grade students with high and low caries experience ( 195 ) or among all second- and fifth-grade students ( 196 ). NPDDP documented only a limited reduction in dental caries attributable to fluoride mouthrinse, especially when children were also exposed to fluoridated water. The evidence for using fluoride supplements to mitigate dental caries is mixed. Use of fluoride supplements by pregnant women does not benefit their offspring ( 198 ). Several studies have reported that fluoride supplements taken by infants and children before their teeth erupt reduce the prevalence and severity of caries in teeth ( 98,199--207 ), but several other studies have not ( 19,208--212 ). Among children aged 6--16 years, fluoride supplements taken after teeth erupt reduce caries experience ( 213--215 ). Fluoride supplements might be beneficial among adults who have limitations with toothbrushing, but this use requires further study. Clinical trials conducted during 1940--1970 demonstrated that professionally applied fluorides effectively reduce caries experience in children ( 233 ). In more recent studies, semiannual treatments reportedly caused an average decrease of 26% in caries experience in the permanent teeth of children residing in nonfluoridated areas ( 191,234--236 ). The application time for the treatments was 4 minutes. In clinical practice, applying fluoride gel for 1 minute rather than 4 minutes is common, but the efficacy of this shorter application time has not been tested in human clinical trials. In addition, the optimal schedule for repeated application of fluoride gel has not been adequately studied to support definitive guidelines, and studies that have examined the efficacy of various gel application schedules in preventing and controlling dental caries have reported mixed results. On the basis of the available evidence, the usual recommended frequency is semiannual ( 151,237,238 ). Studies conducted in Canada ( 242 ) and Europe ( 243--246 ) have reported that fluoride varnish is efficacious in preventing dental caries in children. Applied semiannually, this modality is as effective as professionally applied fluoride gel ( 247 ). Some researchers advocate application of fluoride varnish as many as four times per year to achieve maximum effect, but the evidence of benefits from more than two applications per year remains inconclusive ( 240,246,248 ). Other studies have reported that three applications in 1 week, once per year, might be more effective than the more conventional semiannual regimen ( 249,250 ). Combinations of Fluoride Modalities Studies comparing various combinations of fluoride modalities have generally reported that their effectiveness in preventing dental caries is partially additive. That is, the percent reduction in the prevalence or severity of dental caries from a combination of modalities is higher than the percent reduction from each modality, but less than the sum of the percent reduction of the modalities combined. Attempts to use a formula to apply sequentially the percent reduction of an additional modality to the estimated remaining caries increment have overestimated the effect ( 151,253 ). For example, if the first modality reduces caries by 40% and the second modality reduces caries by 30%, then the calculation that caries will be reduced by a total of 58% (i.e., 40% plus 18% [30% of the 60% decay remaining after the first modality]) will likely be an overestimate.
Liquids – soft drinks, fruit drinks, cocoa, sugar and honey in beverages, nondairy creamers, ice cream, sherbet, jello, flavored yogurt, pudding, custard, popsicles. Solid and Sticky – cake, cupcakes, donuts, sweet rolls, pastry, canned fruit in syrup, bananas, cookies, chocolate candy, caramel, toffee, jelly beans, other chewy candy, chewing gum, dried fruit, marshmallows, jelly, jam Slowly Dissolving – hard candies, breath mints, antacid tablets, cough drops
“ Occlusal Sealing” – 1965 Mixing methyl-2-cyanoacrylate with poly(methyl methacrylate) and inorganic powder then placed in pits and fissures. Polymerized on exposure to moisture
Debris and/or saliva contamination – use a hydrophilic primer to dry the tooth surface and thoroughly clean the tooth Air inclusion during manipulation – surface voids which can discolor and retain plaque Manipulating self-cured sealants late in the setting reaction can disrupt polymerization and induce bond failure
(Bis-GMA) Bisphenol A-glycidyl methacrylate resins 3 parts composite resin mixed with a diluent (methyl methacrylate or triethylene glycol dimethacrylate) – to obtain a low-viscosity sealant Sealants with fluoride – Glass ionomer Anticariogenic- high fluoride content Since viscous it is difficult to gain penetration to the depth of the fissure. This lack of penetration makes it difficult to obtain mechanical retention to the enamel surface to the same degree as Bis-GMA resins
Filler makes sealant more wear resistant and more visible upon clinical inspection Filler – fumed silica or silanated inorganic glasses Unfilled sealants are clear making detection difficult. Less resistant to wear over the long term. Best used when high spots can’t be adjusted i.e. school based setting.
The surface of the substrate be clean The adhesive wet the substrate well, have a low contact angle, and spread onto the surface Adaptation to the substrate produce intimate approximation of the materials without entrapped air or other intervening materials The interface include the sufficient physical, chemical, and/or mechanical strength to resist intraoral forces of debonding The adhesive be well cured under the conditions recommended for use.
Avoid rubbing the etched surface during etching and drying because the roughness developed can easily be destraoyed. The etched area should extend beyond the anticipated area for sealant application to secure optimum bonding along the margin aad reduce the potential for early leakage.
Inadequate rinsing permits phosphate salts to remain on the surface as a contaminant, interfering with bond formation
Bond agent will improve retention especially when there appears to be minor moisture or salivary contamination.