1. Clinical Aspects of Dental Sealants: Materials and Application National Primary Oral Health Care Conference Kevin J. Donly, DDS, MS Professor and Chair Department of Pediatric Dentistry University of Texas Health Science Center at San Antonio

2. 70% of molars (years 1950–1980) develop occlusal caries (Eklund and Ismail, J Publ Health Dent, 1986)

3. Lewis and Hargreaves (1975) Investigated occlusal caries in permanent first molars in a four year longitudinal study of 142 five year old children (Fluoride < 0.1 ppm). Age % of 1 st Permanent Molars Carious 6 64 7 80 8 93

4. CLINICAL STUDIES OF Bis-GMA SEALANTS StudyTime Sealant Retained* Caries Reduction mos % * Completely present, data for permanent teeth Roydhouse 40 3629 Buonocore 9 2487 99 Rock 38 248099 Horowitz et al. 22 247367 Courley 19 247857 Merrill et al. 33 1555 Going et al. 18 246955 Meurman & Heiminen 34 368088

5. Occlusal caries in children have significantly decreased Third National Health and Nutrition Examination Survey

6. Changes in Caries Levels in U.S. Health Surveys (Early 1970s to Early 1990s)

7. Is There a Need for Dental Sealants?

8. Occlusal vs. Aproximal Caries in the USA Burt, et.al. IDR 67, 1988, p.1422

9. 15-Year Single Sealant Application Recall (Simonsen, JADA 122:34-42, 1991)

10. Retention of White Sealants by Surface on Permanent First Molars 5 Years10 Years15 Years Complete retention 82% (173)56.7% (131)27.6% (53) Partial retention 10.9% (23)20.8% (48)34.5% (68) Missing 0.5% (1)6.9% (16)10.9% (21) Restored/ carious 6.6% (14)15.6% (36)26% (50) Total 100% (211)100% (231)100% (192)

11. Sound vs. Carious or Restored Surfaces on Permanent First Molars at 15 Years Group with Sealant Group without Sealant Sound surfaces68.8% (88)17.2% (22) Carious or restored surfaces 31.3% (40)82.8% (106) Total surfaces100% (128) Matched pair analysis (n = 128 surfaces, 16 subject pairs)

12. 5-Year Study; Fluoridated Community o Sound Surfaces - Non-sealed – 13% caries - Sealed – 8% caries o Incipient or Questionable Surfaces - Non-sealed – 52% caries - Sealed – 11% caries (Heller et al, J Publ Health Dent, 1995)

13. Indications for Sealants to Prevent Occlusal Caries

14. Workshop on Guidelines for Sealant Use o Caries risk assessment of the individual and the tooth are important as determinants of sealant need. o Caries risk on surfaces with pits and fissures may continue into adulthood; therefore, post-eruptive age alone should no-longer be used as a major criterion for sealant decisions. o Sealants should be used to prevent caries in at-risk teeth (preventive sealants). o Sealants should be used to treat teeth with questionable caries or definite caries confined to the enamel pits and fissures (therapeutic sealants). o Sealed teeth need to be evaluated periodically for sealant integrity and retention. (Siegal, J Publ Health Dent, 1995)

15. AAPD Recommendations The dental literature supports: 1.Bonded resin sealants, placed by appropriately trained dental personnel, are safe, effective and underused in preventing pit and fissure caries on at risk surfaces. Effectiveness is increased with good technique, appropriate follow-up, and resealing as necessary. 2.Sealant benefit is increased by placement on surfaces judged to be at high risk or surfaces that already exhibit incipient carious lesions. Placing sealant over minimal enamel caries has been shown to be effective at inhibiting lesion progression. Appropriate follow-up care, as with all dental treatment, is recommended.

16. 3.Presently, the best evaluation of risk is done by an experienced clinician using indicators of tooth morphology, clinical diagnostics, past caries history, past fluoride history and present oral hygiene. 4.Caries risk and, therefore, potential sealant benefit, may exist in any tooth with a pit or fissure at any age, including primary teeth of children and permanent teeth of children and adults.

21. Mertz-Fairhurst et al. Cariostatic and Ultraconservative Sealed Restorations: Nine-Year Results Among Children and Adults. ASDC J Dent Child, 1995 vs. Weerheijm et al. Sealing of Occlusal Hidden Caries Lesions: An Alternative for Curative Treatment? ASDC J Dent Child, 1992

22. Minimal Decay vs. Extensive or Rampant Decay  Importance of screening children in School-Based Sealant Programs and referring those to a Dental Home most in need of comprehensive dental care.

23. Types of Sealants  Self cure  Light cure  Unfilled resin  Filled resin  Color changing  Self etching  Fluoride releasing

26. Clinpro Sealant (3M ESPE)

27. Helioseal Clear Chroma (Ivoclar)

28. Self Etch Sealant and Hydrophilic Sealant

29. Fluoride Releasing Sealants o Glass Ionomer o Fluoridated Resin

30. Lesion Initiation (Mean ± S.D.)  Control Sealant138 ± 18µm  Fluoride Sealant109 ± 21µm  GIC 83 ± 12µm (Hicks & Flaitz, Am J Dent, 1992)

31. Acid Etch vs. Air Abrasion  Kanellis et al., 2000 (J Pub Health Dent)  Berry and Ward, 1995 (Quintessence Int)

34. How Long Should Primary Enamel be Etched?  Redford, Clarkson and Jensen, 1986 (Pediatr Dent)

35. Etch Depths (microns) in Primary Enamel after Different Etching Times with 37% Phosphoric Acid Etch Times 15s30s60s120s Mean Depth9121450

36. Bond Strength (kg/cm 2 ) of Sealant after Different Etching Times Etch Times 15s 30s 60s 120s Mean 92 92 83 83 S.D. 177 161 142 145 # of Samples 13 21 17 13

37. 5.Sealant placement methods should include careful cleaning of the pits and fissures without removal of any appreciable enamel. Some circumstances may indicate use of a minimal enameloplasty technique. 6.A low-viscosity, hydrophilic material bonding layer as part of or under the actual sealant has been shown to enhance the long-term retention and effectiveness.

38. Enameloplasty Air abrasion Minimally invasive burs

39. Bonding Agent Prior to Sealant Placement  Hitt and Feigal, 1992 (Pediatr Dent)  Feigal et al., 1993 (JADA)  Feigal et al., 2000 (J Dent Res)

40. PRIME & BOND 2.1 (Caulk/Dentsply)

41. Sealant Placement Technique  At risk surface  Tooth isolation  Clean surface  Etch with 35% phosphoric acid for 15–30 seconds  Bonding agent  Place sealant  Cure sealant  Check occlusion  Re-evaluate

45. ONE-STEP® (Bisco)

49. 7.Glass ionomer materials can be used as transitional sealants, and may prove to be effective as longer-term pit and fissure sealants. 8.The profession must be alert to new preventive methods effective against pit and fissure caries. These may include changes in dental materials or technology.

50. Glass Ionomer Sealants

56. Bisphenol A 90–931 µg/30 ml saliva Environmental Health Perspectives March 1996

57. 1.50% uncured bisphenol A leaches within 3 hours (Ferracane, 1990). 2.Saliva dose not equal to blood dose. 3.Estrogenic effects in breast cancer cells, not normal cell culture

58. THANK YOU!