The Role of Fissure

Sealants in Caries
Prevention

Prepared by Dr. Margaret Stacey

 Learning Objectives

Students should be able to discuss/describe:

• The change in presentation and rate of progression of
occlusal carious lesions with the introduction of fluorides.
• The mechanism by which fissure sealants prevent
occlusal caries.
• Appropriate evidence-based use of fissure sealants for
primary and secondary prevention.
• Evaluation of the adequacy of a fissure sealant.
 Fissure Sealants
we can apply these to early enamel caries.

• Fissure sealants were developed in the 1960’s for use on newly

erupted posterior teeth to prevent the initiation of dental caries in
occlusal fissures (Primary Prevention).
Image accessed at
www.dentistatcare.com.au/children.html this pink material is the fissure sealant.

Image from: Burrow J et al., ADJ 20003; 48(3): 175-179

Image accessed at
www.dentalcareglebe.com.au/Sealants
 Fissure Caries Pre-fluoridation

- Pit and fissure caries commonly progressed at a fast

rate.

- Often detected clinically because of gross cavitation.

- Detection usually occurred within two years of eruption

(sometimes within a few months of eruption).
REF: Backer Dirks O. Post eruptive changes in dental enamel. J. Dent. Res. 1966;
45(Supplement to No.3): 503-511.
 Effect of Fluoride on the Rate of Progession and
Diagnosis of Pit and Fissure Caries

- Pit and fissure caries post-fluoridation is generally more slowly-progressing.

Ripa LW. J Public Health Dent. 1988; 48(1):8-13.
Dummer PM et al., J Dent. 1990; 18(4):190-197.

- Remineralizing effects of fluoride at the opening of the fissure may mask the
lesion.

- Using traditional visual diagnostic criteria occlusal lesions could take up

to 10-20 years to reach the stage where they were detected clinically.

- Many occlusal lesions were not identified until they were well into dentine.

HOWEVER

- ICDAS-II criteria for visual examination identify caries at a much earlier

stage than traditional visual criteria.
this is for occlusal and free smooth surfaces lesions
 Fissure Sealants
• Fissure sealants were developed in the 1960’s for use on newly
erupted posterior teeth to prevent the initiation of dental caries in
occlusal fissures.
Image accessed at
www.dentistatcare.com.au/children.html

Image from: Burrow J et al., ADJ 20003; 48(3): 175-179

Image accessed at
www.dentalcareglebe.com.au/Sealants
 How do fissure sealants prevent caries?
when acid is applied, there is dissolution in the enamel and there is
roughened surface and when you apply the sealant, it will go into the
depressions and it locks in

• Sealants occlude the fissure and sealant tags penetrate

etched enamel to provide a bond.

• Bacteria that are trapped underneath an intact sealant are

deprived of fermentable carbohydrates.

• When bacteria are deprived of nutrients, they are unable to

produce acid and caries cannot initiate/progress.
 Bonding of Sealant to
Etched Enamel

SEM of cross-section depicting

cured resin adhering to etched
bovine enamel.
R = cured resin
H = hybridized enamel

Enamel was etched with

phosphoric acid (H3PO4) at
concentrations 3, 5, 10, 20, 35,
and 65% respectively in images
3.1 – 3.6.
This shows effect of phosphoric action of different concentration.

Image from: Shinichi et al., Dental Materials, 2000; 16:324-329.

 Bonding of Sealant to Etched Enamel

Light microscope images of thin cross-sections of bonded specimens that depict

resin tags after the specimens had been soaked in 4 mol/l HCl for 60 secs.
R = cured resin enamel has been dissolved away from the resin. This shows the
resin that has extended into the hole. There is different amount of
T = resin tag penetration as the concentration goes up. There is an optimal
concentration of etching. 65% is way too much.

Image from: Shinichi et al., Dental Materials, 2000; 16:324-329.

Rationale for Use of Fissure Sealants
you always follow the manufacture instructions

PRIMARY PREVENTION (prevention of disease initiation)

- In non-carious newly erupted teeth.

- Generally for individuals who have been determined to

have increased caries risk:

- History of caries in the primary dentition.

- Presence of fissure caries in one or more recently

erupted permanent teeth.

- Teeth with unfavourable fissure morphology

ie. deep, plaque-retentive fissures.
something that is shallower and wider is less retentive
Rationale for Use of Fissure Sealants

SECONDARY PREVENTION
(ie. early treatment of active disease – therapeutic use)

- For teeth with active enamel fissure caries.

- Rationale for use is that fissure caries will arrest when

cariogenic bacteria are sealed off from dietary substrate
and eventually die.

- The lesion will become and remain inactive provided

that the sealant remains intact.
Evidence-based clinical recommendations for
the use of pit-and-fissure sealants.
A report of the American Dental Association Council on Scientific
Affairs. JADA 2008;139(3):257-267.

• Staff of the American Dental Association Division of

Science (expert panel including Ismail, A and Simonsen,
R) conducted a review of the literature.

• Graded the strength of the evidence (I – IV).

• Provided clinical recommendations.

• Strength of the recommendation was graded according

to the strength of the evidence (A – D).
The following clinical questions were some
of the questions considered:

1. Under what circumstances should sealants be placed

to prevent caries?

2. Does placing sealants over early (noncavitated)

lesions prevent progression of the lesions?
this relates to secondary prevention
 Clinical Recommendations
Pit-and-fissure sealant placement for caries
o
prevention. (1 prevention)
1. Sealants should be placed on pits and fissures of children’s
primary teeth when it is determined that the tooth, or the patient,
is at risk of experiencing caries. (III,D) this is grade 3 evidence, hence quite low. Therefore this is not
recommended

2. Sealants should be placed on pits and fissures of children’s and

adolescent’s permanent teeth when it is determined that the
tooth, or the patient, is at risk of experiencing caries. (Ia,B) This is top level
evidence, and hence
stronger
recommendation
3. Sealants should be placed on pits and fissures of adult’s
permanent teeth when it is determined that the tooth, or the
patient, is at risk of experiencing caries. (Ia,D)
 Clinical Recommendations
Pit-and-fissure sealant placement over early (non-cavitated)
o
carious lesions to prevent progression. (2 prevention)
1. Pit-and-fissure sealants should be placed on early (non-cavitated)
carious lesions, as defined by this document, in children, adolescents
and young adults to reduce the percentage of lesions that progress.
(Ia,B) recently erupted teeth. good evidence and good recommendation

2. Pit-and-fissure sealants should be placed on early (non-cavitated)

carious lesions, as defined by this document, in adults to reduce the
percentage of lesions that progress. (Ia,D) strong evidence but not recommended. these caries will be
arrested at this age

“Non-cavitated carious lesions” refers to pits and fissures in fully erupted teeth that
may display discolouration not due to extrinsic staining, developmental opacities or
fluorosis. The discolouration may be confined to the size of a pit or fissure or may
extend to the cusp inclines surrounding a pit or fissure. The tooth surface should
have no evidence of a shadow indicating dentinal caries, and, if radiographs are
available, they should be evaluated to determine that neither the occlusal or proximal
surfaces have signs of dentinal caries.
A small, distinct dark brown
early (non-cavitated) carious
lesion within the confines of
the fissure (ICDAS-II code 1).
1 & 2.
Small light brown early
(non-cavitated) carious lesion
does not extend beyond the
confines of the pit and
Fissure (ICDAS-II Code 1).
A more distinct early
(noncavitated) carious lesion
that is larger than the normal
anatomical size of the fissure
area (ICDAS-II code 2).

if these lesions are active, they will be

suitable for sealing
A more distinct early
(non-cavitated) carious lesion
that is larger than the normal
anatomical size of the fissure
area.
Sealants for preventing and arresting pit-and-
fissure occlusal caries in primary and permanent
molars. A systematic review of randomized controlled trials – a
report of the American Dental Association and the American Academy
of Paediatric Dentistry. JADA 2016; 147(8): 672-682.

• 23 studies met inclusion criteria.

Findings:
• There is moderate quality evidence that participants who received
sealants had a reduced risk of developing carious lesions in occlusal
surfaces of permanent molars, compared with those who did not
receive sealants.
• Studies comparing effect of sealants with effect of applying fluoride
varnish to fissures provided low quality evidence that application of
sealants may be more beneficial compared with application of
fluoride varnishes after 7 or more years of follow up.
NB: Melbourne Dental School recommends application of fissure
sealant in preference to application of fluoride varnish to fissures.
 Materials
Low Viscosity Materials
Resin-based Fissure Sealants
- Bis GMA (Bisglycidylmethacrylate) - sometimes termed
“conventional resin-based sealants” eg. Delton
- UDMA (Urethane Dimethacrylate) eg. Conseal
Glass Ionomer Fissure sealants
- Conventional GIC fissure sealant (low viscosity) eg. Fuji 3

Higher Viscosity Materials

Resin Based - Flowable resin composite eg. Revolution Formula 2
Glass Ionomer - High viscosity flowable GIC eg. Fuji 7 (pink or white) –
promoted by GC as a better choice for fissure sealing than Fuji 3
because:
- Less wear
- Stronger
- Higher fluoride release
 Clinical Performance
• Retention rates of resin-based sealants are better than for GIC
sealants
Kuhnisch J, Mansmann U, Heinrich-Weltzien R, Hickel R. Longevity of materials for pit and fissure sealing
– results from a meta-analysis. Dent Mater 2012; 28: 298-303.

• Retention rates for the higher viscosity flowable materials are

higher than for the lower viscosity materials.
- Retention rates for flowable composite sealants are higher than for
conventional resin composite sealants.
Bagerian A and Sarraf Shiraz A. Flowable composite as fissure sealing material? A systematic review and
meta-analysis. BDJ 2018; 224: (2): 92-97.

- High viscosity GIC sealants have higher retention rates than low
viscosity GIC sealants.
Chen X, Minquan D, Fan M, Mulder J, Huysmans M-C, Frencken JE. Effectiveness of two new types of
sealants: retention after 2 years. Clin Oral Invest 2012; 16: 1443-1450.

• Caries preventive effect of retained resin-based and glass ionomer

sealants is similar.
Yengopal V, Mickenautsch S, Bezerra AC, Leal SC. Caries-preventive effect of glass ionomer and resin-based
fissure sealants on permanent teeth: a meta analysis. J of Oral Sci 2009; 51: (3); 373-382.
 Clinical Use of Sealants
PRIMARY PREVENTION (Sound Fissures)
• Apply sealant as soon as possible after eruption.

• Fully erupted teeth

- apply resin-based sealants
- always use rubber dam; successful bonding is dependent on
good moisture control.

• Partially erupted teeth

– apply GIC sealants if moisture control is difficult.
- apply high viscosity GIC with finger pressure – improves retention
rates. Beiruti N, Frencken JE, Mulder J. Am Dent J 2006; 19: 159-162.
- Apply resin-based sealant at a later stage when GIC has been
lost and the tooth has erupted enough to apply rubber dam.

SECONDARY PREVENTION (Early Active Fissure Caries)

- Apply resin-based sealants on active early (non-cavitated)
occlusal lesions.
 Clinical Recommendations

• Students must follow technique taught in preclincal

laboratory.
• Rubber dam should be used when placing fissure
sealants on fully erupted teeth.

Sealants should be monitored and reapplied as necessary

to maximize effectiveness.
 Maintenance of Fissure Sealants

- As with all dental materials, fissure sealants may be lost

or deteriorate.
can be due to wear, or crack or fracture out

- Patients need to be informed that they will need to have

minor repairs or replacements from time to time.
 Evaluating Fissure Sealants
When evaluating fissure sealants at recall examinations the
following aspects should be considered:

Coverage - The entire fissure system should be

covered, with an adequate quantity of sealant.

Porosity - Visible porosities must be repaired (they may

communicate with the fissure thereby allowing
substrate to reach the cariogenic bacteria and
activate the lesion).

Retention – Sealants may be partially or totally lost.

Partially retained fissure sealants in first and second molars

Image from: Heveinga MA et al. Journal Of Dentistry, 2010. 38:23-28.

 Repair of Fissure Sealants
1. Isolate the tooth.
2. Use a bristle brush or rubber cup with pumice to clean the tooth.
3. Rinse the tooth thoroughly to remove all traces of pumice.
4. Roughen the surface of the sealant at the fracture line with a round
slow-speed stainless steel bur or a round slow-speed diamond
composite finishing bur where the addition is to be made.
5. Rinse away slurry of resin.
6. Apply etchant to the fissure system (to etch enamel) and fractured
edge of sealant (to remove any remaining slurry).
7. Wash and thoroughly dry the tooth.
8. Apply and cure the sealant.
 Learning Objectives

Students should be able to discuss/describe:

• The change in presentation and rate of progression of
occlusal carious lesions with the introduction of fluorides.
• The mechanism by which fissure sealants prevent
occlusal caries.
• Appropriate evidence-based use of fissure sealants for
primary and secondary prevention.
• Evaluation of the adequacy of a fissure sealant.