Introduction
Pits and fissures of the occlusal surfaces of the posterior teeth are more prone to caries development than the smooth surfaces due to their morphological complexity, making dental hygiene more challenging and leading to increased plaque accumulation.[1]The enamel in pits and fissures cannot receive the same protection from fluorides compared to the enamel on smooth surfaces.[2]
The use of pit and fissure sealants provides a physical barrier that inhibits microorganisms and food particle accumulation, preventing caries initiation and arresting caries progression.[3][4]Permanent first molars, followed by second molars, show the highest prevalence of caries. The management of occlusal caries on permanent molars represents a significant challenge because the onset of caries occurs soon after they erupt into the oral cavity. The effectiveness of pit and fissure sealants depends on their long-term retention.[4]
Anatomy and Physiology
The morphology of the occlusal surface of the molars is extraordinarily variable. Occlusal fissures are deep invaginations of enamel that can be extremely diverse in shape and have been described as broad or narrow funnels, constricted hourglasses, and multiple invaginations with inverted Y-shaped divisions and irregularly shaped.
V type:Wide at the top and gradually narrowing towards the bottom; shallow and wide; tend to be self-cleaning and somewhat caries-resistant; noninvasive techniques are recommended
U-type:Shallow and wide; tend to be self-cleaning and somewhat caries-resistant; a noninvasive technique is recommended
I-type:Extremely narrow slit; deep, narrow, and constricted, resembling a bottleneck; caries susceptible and may require invasive technique
IK- type:A narrow slit associated with a larger shape at the bottom; may require invasive technique and are very susceptible to caries
Because of morphological variations, it is not always possible to categorize a tooth as having one particular type of fissure.[2]
Indications
Pit and fissure sealants can be utilized as aprimary prevention tool when the tooth or the patient is at an increased risk of experiencing caries or as a secondary prevention method interrupting the progression of incipient caries.
The indications for placing a pit and fissure sealant are as follows:
Pits and fissures of deciduous teeth in children when the tooth, or the patient, is at an increased risk of experiencing caries[5]
Pits and fissures of permanent teeth in children and adolescents when the tooth, or the patient, is at risk of experiencing caries[6][7]
Pits and fissures of permanent teeth in adults when the tooth, or the patient, is at risk of experiencing caries[6][7]
Incipient carious lesions (noncavitated) of pits and fissures in children, adolescents, and adults[8]
Pits and fissures of primary and permanent teeth should be considered in children and young people with medical, physical, or intellectual disabilities, mostly when systemic health could be jeopardized by dental disease or the need for dental treatment.[9]
Contraindications
Dental professionals should decide to place a pit and fissure sealant based on the patient's risk, not the age or time lapsed since tooth eruption.[10]If the patient does not exhibit any risk factors or is at low risk of developing carious lesions, there is no need to perform this preventive measure at that time. However, it is essential to highlight that all children should be regularly monitored for any changes in cariogenic risk factors or clinical or radiographic changes.[9]
Equipment
There are2 main materials used in pit and fissure sealants, resin-based and glass ionomer sealants. Resin-based sealants are the firstchoice of treatment,andglass ionomer sealants may be utilized as a provisional agent when the placement of a resin-based sealant is indicated, but absolute isolation cannot be achieved, and therefore moisture control is compromised. Glass ionomersealantscontain fluoridethat can help to prevent caries through their release over a prolonged period.[11]
The rest of the equipment typically includes:
Air/water syringe
Mouth mirror
Explorer
Excavator tip
Two by two gauze squares
Cotton rolls
Cotton pellets
Forceps/cotton pliers
Articulating paper
Curing light
Handpiece
Dappen dish with pumice
Preparation
The need and the method for surface cleansing of pits and fissures before placing a sealant may seem controversial. Some authorshave suggested using pumice or air-polishing instrumentsto obtain an optimal acid-etch pattern of the enamel. At the same time, others believe that acid etching alone is sufficient for surface cleaning.[9]
Technique or Treatment
Isolation of the Tooth
Moisture control is the most crucial aspect of the pit and fissure sealant placement, and therefore absolute isolation using a rubber dam is preferred. As a result of inadequate isolation, the enamel porosities formed during etching can be filled by any fluid blocking the resin tags, decreasing the retention of the material. There are cases where absolute isolation is not possible, or it is not practical, like in the case of newly erupted teeth due to the need for local anesthesiato place theclamp. In such cases, a dry field can be achieved by cotton rolls and isolation shields, and clever use of the evacuation tip. The application of glass ionomer may be considered as a temporary measure.
Acid Etching
Most frequently used: 37% orthophosphoric acid (gel)
Gel applied either directly with special application tips or with a small disposable brush
Should be applied to all the susceptible pits and fissures and extend up to cuspal inclines
Etch for 15 seconds for permanent molars, 15 to 30 seconds for primary teeth. Teeth with dental fluorosis require additional etching time
If glass ionomer cement is being used, etching is not required, and a surface conditioner may be used
Rinse well with air-water spray
Dry the tooth with uncontaminated compressed air until a frosty white opaque appearance is seen
If cotton roll isolation has been used, replace cotton rolls
If this appearance is not seen, repeat acid etching
If the surface becomes contaminated, re-etching must be done[12]
Sealant Placement and Curing
Many sealant kits have their own dispensers and instructions that must be followed.
Apply sealant, allow to flow into pits and fissures
In mandibular teeth, apply the sealant from the distal aspect, allowing flowing mesially
In maxillary teeth, apply the sealant from the mesial aspect, allowing it to flow distally
Use a fine brush, mini sponge, and carry sealant material up to the cuspal inclines
Air bubbles should not be incorporated
Visible Light Cured Sealant
10 to 20 seconds: exposure to visible light
The tip of curing light should be held 3 to 5 mm from the surface of the sealant
After the sealant has set, wipe the surface with a wet cotton pellet so that air inhibited layer of non-polymerized resin is removed and failure of this step leaves an objectionable taste in the patient's mouth
Evaluate the Sealant
Visually and tactically
Evaluate the Occlusion of Scaled Tooth Surfaces
Check the occlusion with articulating paper – round finishing bur
Annual recall: 5% to 10% of sealants require repair or replacement annually
The retention of sealants can be evaluated through visual and tactile examinations. When the sealant has been lost or partially retained needs to be reapplied [4]
Follow-up
Sealed surfaces should be clinically and radiographically regularly monitored. Bitewing radiographs are recommended for radiographical assessment, which should be performed as often as the risk status indicates it. However, the risk status may change over time; for that reason, other susceptible sites, like proximal surfaces, should be monitored.
In the case of defected sealants, dentists must reapply them to maintain marginal integrity.[9]
Complications
An unsuccessful pit and fissure sealant placement may be due to:
Contamination may resultfrom either saliva or calcium phosphate products
Inadequate surface preparation
Incomplete or slow photopolymerization
Air entrapment
Overextension of the material beyond the conditioned tooth surface
Toxicity
According to a few studies, the release of significant sealant components, like bisphenol A (BPA), impairs animal development, health, and reproductive systems. However, the American Association of Pediatric Dentistry Guidelines, the US Drug and Food Administration (FDA), and the American Dental Association (ADA) have concluded that low BPA exposure from dental sealants poses no known health risks.
Clinical Significance
It is estimated that about one-fourth of children and more than one-half of adolescentspresent dental carious lesions in their permanent teeth.[13]The occlusal surfaces of the posterior teeth are the most susceptible to caries development due to pits and fissures with complex morphologies that make them the perfect habitat for caries development. There is sufficient evidence to believe that sealants are an effectivemethod to prevent this undesired disease.A study performed in children has shown a 37% decreased risk of dental caries with the placement of pit and fissure sealants compared with the control group. Compared to no sealant use, pit and fissure sealants reduced the risk of developing dental caries by 44% after three years in thefirst permanent molars.[3]Caries risk assessment is the most important part of thedecision-making process, and there is a need to periodically reevaluate a patient’s caries risk status.
Enhancing Healthcare Team Outcomes
Pit and fissure sealants can be used as primary prevention, anteceding the development of dental caries, or as a secondary prevention measure to stop the disease progress. It is atool for caries prevention individually or as part of a public health measure for at-risk populations.[4]Therefore, it is imperative that all dental specialties professionals, including preventive dentistry, public health dentistry, restorative dentistry, pediatric dentistry, oral medicine, endodontics, and general dentistry professionals, are aware of the high prevalence of pit and fissure caries and that dental sealants should be indicated based on a caries risk assessment in each patient.
References
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Carvalho JC. Caries process on occlusal surfaces: evolving evidence and understanding. Caries Res. 2014;48(4):339-46. [PubMed: 24577073]
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Rohr M, Makinson OF, Burrow MF. Pits and fissures: morphology. ASDC J Dent Child. 1991 Mar-Apr;58(2):97-103. [PubMed: 2050885]
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Liu W, Xiong L, Li J, Guo C, Fan W, Huang S. The anticaries effects of pit and fissure sealant in the first permanent molars of school-age children from Guangzhou: a population-based cohort study. BMC Oral Health. 2019 Jul 16;19(1):156. [PMC free article: PMC6636114] [PubMed: 31311541]
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Welbury R, Raadal M, Lygidakis NA., European Academy of Paediatric Dentistry. EAPD guidelines for the use of pit and fissure sealants. Eur J Paediatr Dent. 2004 Sep;5(3):179-84. [PubMed: 15471528]
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Disclosure: Athira Sreedevi declares no relevant financial relationships with ineligible companies.
Disclosure: Melina Brizuela declares no relevant financial relationships with ineligible companies.
Disclosure: Shamaz Mohamed declares no relevant financial relationships with ineligible companies.
