Supporting Sealant Retention

Pit and fissure decay is responsible for roughly 80% to 90% of all carious lesions in secondary teeth, and 44% of caries in primary teeth.¹ These dismal statistics can be greatly reduced through the placement of sealants on teeth susceptible to caries.¹ Not only can pit and fissure sealants be placed to prevent caries, they can also be placed over incipient lesions in order to arrest decay.²

Once the sealant material polymerizes and as long as the sealant remains in place, it is highly effective against Class I caries.³ The success of sealants is connected to their retention.⁴ As such, the materials and approach to surface preparation should be chosen carefully to support their retention and, thus, their ability to prevent decay. Timing of sealant placement is also important. Teeth are most susceptible to caries within the first 2 years to 3 years of eruption so sealants should be placed before the end of this critical window.⁵

MATERIALS

The use of resin-based sealant materials is common. These products frequently comprise urethane dimethacrylate or bisphenol A-glycidyl methacrylate monomers, which requires a dry field during the application process.^6–8 However, resin-based sealant products that do not require a dry field are also available. The most significant benefit to resin-based sealant materials is their improved retention rates over glass ionomer materials.^7,9

Composed of aluminosilicate glass and polymeric water-soluble acid that react to form a paste, glass ionomer sealant materials are another option in the caries-prevention armamentarium. While they do not offer the same retention rates as resin-based sealants, they do offer some unique benefits.^10,11 First, they release fluoride which can be helpful in high-risk patients. Second, glass ionomer sealants can be set in a moist field, so if isolation is difficult to achieve, glass ionomer may be the best option.¹²

PREPARING FOR THE TOOTH SURFACE

Sealant-placement technique is important in order to maximize retention. Preparing the tooth is one of the first steps. Numerous studies have been performed on the most effective way to prepare the tooth surface for a dental sealant.^13–19

A meta-analysis concluded that air abrasion, polishing, and bur preparation were more effective than bristle brushing.¹³ The authors also determined that in order to be most effective, these preparation approaches should be used along with an acid-etch technique. Other studies have researched the difference between air abrasion and mechanically preparing the tooth surface with a bur. Enamoplasty prior to sealant placement reduces the amount of leakage around the sealants, and improves retention when compared with less invasive techniques, such as air abrasion.¹⁴ Bur preparation does not come without concerns. If bur preparation has been performed prior to sealant placement and the sealant is lost, the pits and fissures may become more susceptible to caries.¹³

The use of adhesives prior to sealant placement has been an area of interest for sealant research. In a recent meta-analysis, researchers evaluated the retention of dental sealants with an adhesive compared to those placed without an adhesive.¹⁵ The first half of the study looked at the effectiveness of preparing the tooth with an adhesive prior to sealant placement. They concluded that using an adhesive positively affected the retention of the dental sealants. In the second portion, researchers found that when an adhesive was used, an etch and rinse system is recommended over other types.¹⁵

Another meta-analysis aimed to determine if self-etch adhesive systems were effective in sealant retention. The authors found that because self-etch adhesives do not have the same level of acidity, they do not provide the same level of etching as phosphoric acid.⁴ They suggested that oral health professionals use the acid-etching technique for long-term sealant effectiveness.⁴ A separate study found that not only do adhesives help with retention percentages, but that they also assist in preventing microleakage around the sealants themselves.¹⁴

Etchant times is also of interest. Because etchant timing does not have an effect on retention, instances of contamination could be decreased by reducing the etchant time.¹⁶ If practitioners are not waiting for longer etchant periods, there is less likelihood of saliva contaminating the surface.

There was some belief that applying topical fluoride immediately before the sealant application may reduce the effectiveness and retention of the sealant. It has been determined that topical fluoride application prior to sealant placement does not impact the retention of the new sealant.¹⁴ This could help eliminate an additional appointment if the dental hygienist can apply the sealant after the exam at recare visits.

PLACEMENT TECHNIQUE

Isolation is an important factor during sealant placement for some resin-based sealant materials. If a tooth becomes contaminated with saliva during the procedure, and re-etching does not occur, the sealant will not be successful.¹⁷ Cotton rolls, saliva ejectors, rubber dams, and isolation systems help to maintain a dry field for sealant placement. Because most resin materials are only successful in a dry environment, a four-handed technique is superior to a two-handed technique in order to control the amount of moisture surrounding the tooth. With four-handed dentistry, high-volume evacuation is used by an assistant to maintain a dry field for those sealant materials that need one.^1,6

Multiple studies have shown that dental auxiliaries have a high success rate with dental sealant placement.^20–22 The retention of sealants should be checked regularly and repairs should be provided as needed.¹⁷

APPROPRIATE AGE FOR PLACEMENT

Research indicates that overweight/obesity can cause acceleration of ­permanent molar emergence.¹⁹ Due to the rise in childhood obesity throughout the United States, research is needed to investigate whether this affects when teeth typically erupt. Further studies will help determine at what age school-based sealant programs should begin.¹⁹ Many sealant programs take place in second and sixth grade. Now that eruption time may be changing, it would be important to consider completing such programs 6 months to 12 months earlier.¹⁹

CONCLUSION

Materials, surface preparation, and timing are all important considerations for dental sealant placement. Oral health professionals are charged with helping patients achieve and maintain their dental health. Dental sealants are an effective strategy in the prevention of dental caries. Unfortunately, sealant utilization remains low. According to research conducted by Pew Charitable Trusts, 6.5 million low-income children ages 6 to 11 do not have dental sealants.²³ Promoting the use of sealants as an effective way to reduce caries is important to improving the oral health of all Americans.

REFERENCES

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23. Pew Charitable Trusts. When Regulations Block Access to Oral Health Care, Children at Risk Suffer. Available at: pewtrusts.org/en/research-and-analysis/issue-briefs/2018/08/when-regulations-block-access-to-oral-health-care-children-at-risk-suffer. Accessed October 22, 2018.

From Dimensions of Dental Hygiene. November 2018;16(11):21–22.