Journal of Minimum Intervention in Dentistry

J Minim Interv Dent 2011; 4 (2) Sealant application is a non-invasive procedure that consists of filling the pits and fissures of a tooth. It creates a smooth, flat, impermeable barrier that stops bacterial plaque accumulating and prevents demineralisation of the protected surface. The clinical success of sealants has been described in many clinical studies. Sealants can be applied preventively, to prevent carious lesions appearing, or to treat and stop the carious process. This article sets out the indications for using this non-invasive procedure and provides some facts about protocol. Indications Indications for preventive sealants Preventive sealants are indicated for patients with a high caries risk. They are usually applied to young patients with no lesions, but with teeth erupting, because during eruption, tooth enamel is immature and fragile. Furthermore, since the teeth are below the occlusal plane during this period, they are more difficult to reach during tooth brushing, and are cleaned only poorly by the natural processes of mastication, and friction from the tongue, cheeks and lips. Preventive sealing is part of the "Prevent" stage of MI treatment in Cariology. Indications for therapeutic sealants Therapeutic sealants are part of the "Restore" stage of MI treatment in Cariology, because they restore the integrity of the dental surface without invading the dental tissue. They do this by sealing early carious lesions. Their effectiveness is due to the fact that they decrease the bacterial flora to below the lesion progression threshold. They only remain effective if the seal remains intact, which is why patient follow-up is so important in this treatment, and why it is important to include other preventive measures such as advice on eating habits and oral hygiene. Although the technique is little used, it is not new, and was described by Elderton in 1985. The technique is indicated for confirmed lesions in the context of Minimum Intervention dentistry for patients with caries risk factors under control. Sealing is indicated for enamel lesions, early stage dentine lesions and when the presence of a lesion is uncertain. If the carious process has been properly arrested (balance between pathological and protective factors), a sealant is applied for preventive reasons, but if the lesion still appears to be active, the sealant is termed therapeutic. The surgical procedure is identical in both cases.

Minimal Intervention in Cariology Preventive and therapeutic sealants

Decerle N , Domjean S
1 1 1

CHU Clermont-Ferrand, Service dOdontologie, Htel-Dieu, F-63001 Clermont-Ferrand, France ; Univ Clermont1, UFR dOdontologie, EA 3847, F-63000 Clermont-Ferrand, France

Sealant application is a non-invasive procedure consisting of filling the pits and fissures of a tooth. It creates a smooth, flat, impermeable barrier that stops bacterial plaque accumulating and prevents demineralisation of the protected surface. The clinical success of sealants has been described in many clinical studies. Sealants can be applied to prevent carious lesions appearing, or to treat and stop the carious process. This article sets out the indications for using this non-invasive procedure and provides some facts about protocol.

Correspondence address: Pr Sophie Domjean CHU Clermont-Ferrand, Service dOdontologie, Htel-Dieu, F-63001 Clermont-Ferrand, France ; Univ Clermont1, UFR dOdontologie, EA 3847, F-63000 Clermont-Ferrand, France Email: sophie.domejean@u-clermont1.fr

Effectiveness of sealants Preventive sealants Applying sealants to pits and fissures is internationally recognised as a means of primary prevention in children and adolescents with a high caries risk. Despite significant limitations due to transposing results from different health systems, an analysis of the literature from the USA, Canada and Australia has shown that: - Sealing the first permanent molars is very costeffective in patients with high caries susceptibility, - For children with low caries susceptibility, the cost benefits are not yet proven.

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Journal of Minimum Intervention in Dentistry

J Minim Interv Dent 2011; 4 (2)

Therapeutic sealants Although clinical studies have not provided clear scientific proof, two articles reviewing the literature give considerable food for thought, and support the idea that sealing initial lesions is a therapy that should be considered. It has been shown that sealing caries lesions reduced the probability of lesion progression: significant reduction in the total number of bacteria and in their viability. Moreover, the remaining bacteria produce no more acid, since the sealant forms a physical barrier against fermentable nutrients from the oral cavity. A recent meta-analysis has concluded that the technique is beneficial for treating initial lesions without cavities in children, adolescents and young adults with a three-fold decrease in the probability of annual progression of carious occlusal lesions in children, adolescents and young adults after sealing, compared with no sealant. Preventive or therapeutic sealant combined with small-size restoration This type of composite restoration is described in English language literature as "Preventive Resin Restoration". The sealant encompasses not only all of the pits and fissures but also the entire restoration with the adjacent enamel. This option is the modern alternative to Black's prophylactic extension of cavity restoration. Although the results of the different clinical trials are variable and difficult to interpret, the clinical performance is good as far as the sealant marginal integrity is preserved. Clinical procedure Which material to use? Glass Ionomer Cements (GIC) or composites? Recent reviews reported that although GICs have lower retention rates than composite resins, results for difference in cariostatic effect do not seem to be significantly different. Therefore it would appear that composite resins are a better choice as a sealant, due to their higher retention rate. GICs can be considered when conditions for using composite resin are not very favourable (impossibility of placing a rubber dam, follow-up uncertain). It is important to note that whichever material is considered, sealant effectiveness depends on the quality of retention, and so on careful following of the protocol for its use. What is the conditioning? Cleaning From the literature, it is not possible to define the cleaning method that gives the best clinical results. By professional consensus, dry mechanical cleaning and air polishing are good options because they do not leave debris liable to alter resin adhesion. best preparation and surface

Surface conditioning From the literature, it is not possible to determine the best ways of preparing and conditioning the enamel, especially when there is a need to prepare the surface by air abrasion before etching. By professional consensus, when using resin-based sealants, simple enamel preparation by etching with 37% orthophosphoric acid seems to be sufficient. No clinical trials have been performed on rinsing and drying the etching agent. Some authors agree that rinsing for 20 to 30 seconds is necessary before very careful drying for 15 seconds; some others believe that it is not useful to specify the exact time of each of the two previous steps, as long as it is possible to obtain a clean dry surface with a chalky white appearance. In the case of GICs, polyacrylic acid or the conditioner supplied by the manufacturer is used for conditioning the surface. Use of an adhesive system The available literature does not show that use of an adhesive system improves the retention of resin-based sealants. Therefore, in the absence of proof, it is better not to overload the operating protocol, and so not put adhesive under composite resin sealants. Isolation The retention of resin-based sealant does not seem to be influenced by the type of isolation (rubber dam or cotton rolls). Nevertheless, difficulty in isolating site is an important factor for the use of a GIC sealant (erupting teeth, young children, phobic dental patient).

Follow-up Sealing fissures is part of a comprehensive prevention and non-invasive approach that demands regular follow-up, varying with individual caries susceptibility. During check-up visits, individual caries susceptibility has to be reassessed and the integrity of the sealant verified. If partial or total loss has occurred, a preventive sealant is respectively repaired or reapplied for patients remaining at high caries risk. If the risk level has decreased, preventive sealant is simply removed. A therapeutic sealant has to be considered like a long-term restoration; if partially or totally lost, it has to be alternatively repaired or replaced whatever the caries risk is at follow-up.

Conclusion Sealing pits and fissures, whether for preventive or therapeutic reasons, is a simple procedure with a well-documented protocol for use. Its success depends on the sealant being watertight, which requires regular follow-up. Like all restorative therapy (invasive or not), it is not standalone, and must be combined with hygiene and advice on food.

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Journal of Minimum Intervention in Dentistry

J Minim Interv Dent 2011; 4 (2)

Figure 1. Decision tree showing the treatment plan for Minimal Intervention in Cariology in four stages as proposed by the GC-MI-Advisory Board. As their name indicates, preventive sealants are part of the "Prevention" stage. Therapeutic sealants are part of the therapeutic strategies available to practitioners in the "Treatment" phase of the diagram, because they allow the dentist to restore the integrity of dental tissue and prevent the development and cavitation of early carious lesions.

Figure 2. Sealants are used on the pits and fissures of the occlusal surfaces of posterior teeth, and also on the vestibular and lingual/palatal surfaces.

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Journal of Minimum Intervention in Dentistry

J Minim Interv Dent 2011; 4 (2)

Figure 3. Therapeutic sealants applied to an initial enamel lesion using a composite fluid under rubber dam isolation. The patient must be followed up to ensure that the lesion is inactive and that factors contributing to caries risk are properly managed.

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