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Lecture outline:

1-continue last topic about fissure sealant.


2-start an introduction about fluoride.

Before you are supposed to do fissure sealant (FS) you should


take a bite-wing radiograph to exclude the presence of proximal
caries
FS and PRR are not applied to teeth which have a proximal
caries...

Technique of placement of FS:


 Isolation: by placing cotton rolls buccally and lingually,
place the suction tube all the time during the procedure until
you are sure that there is a good moisture control, and don't
allow the patient to rinse or close his mouth…(so these are the
rules if you don't use a rubber dam).
 Cleaning the tooth surface.
 Acid etch the occlusal surface for 30 seconds.
 Wash the surface with 3 in 1 syringe not by asking the
patient to rinse.
 Dry it right away and apply FS immediately by a brush
from the dispensary room (‫)من عند العمو إلي دايما مبتسم‬or you can
use a burnisher, you must spread FS on the fissure then light
cure it right away for 20 seconds.
 Check the occlusion relationship with articulating
paper(‫)هاي اختصاصك فكرية‬

 You don't need a bonding agent you just acid etch and
apply FS.
 If FS get detached that means that your moisture
control was not efficient, to solve this problem you must
maintain a good moisture control and you can apply a
bonding agent on the tooth surface after acid etching and
then put the FS.
 If the occlusion surface after applying FS was high you
correct it by using white stone bur.

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Safety issues regarding FS:

Estrogenicity of sealant:
Estrogen (estradiol-major estrogen in the body-) is a hormone
produced by testes and ovaries responsible in reproductive tract, so
how it's related to FS?

***Bis-phenol A(BPA): which is present in FS is:


1. Xenoestrogen.
2. Structurally different from estrogen but has a similar
action.
3. Has a role in breast cancer and decreased sperm count.
4. Presents in the lining of Pepsi cans, pesticides,
preservatives…

A study in 1996 said that BPA is not a direct ingredient of FS; it's
a chemical that appears later after curing when the raw materials
fail to fully react so the residual monomers leak outside of the cured
resin.

Ideally you must cure FS for 20 seconds so if you don't cure it


enough then the problem might appear.

Monomers may be detected in the saliva 1 hr after application of


FS on the tooth.

The amount of BPA required to cause xenoestrogenicity in vitro


(in lab) is 2µg/Kg body wt/day.
And only 1/1000 of this amount of BPA is released in the saliva
and this is not absorbed and may be present in non detectable
amounts in systemic circulationso don't worry about this small
amount.
NO FOUNDATION FOR CONCERN ABOUT
ESTROGENICITY…
But what should you do especially if you have concerned
parents who read about FS and they become worried about their
children???
You have to explain to them that this happens if FS is not
cured well.
A suggestion for clinician who wishes to minimize patient
exposure to uncured component after FS would be:

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1- To apply pumice with rubber cup which you put on slow speed
hand piece, get the pumice (small particles of sand) and wet it with
water until its a paste and use this to abrade FS
2- You can use cotton on FS surface after polymerization.
3-cure the FS for 40 seconds (the ideal is 20s).
So why does FS fail?
1-Moisture contamination which is a common mistake.
Current recommendation to place bonding agent because it's
hydrophilic so even if saliva (very little drop not to have the tooth
swim in the saliva) contaminate it, so it won't actually hurt.
2-Trapped voids when you place FS you have to distribute it on the
fissure surface in order to have no voids.
3-Wearing of tooth structure because the patient may have
bruxism.
4- Marginal leakage because of polymerization shrinkage or
moisture control problems and this will lead to secondary caries.
5- Polymerization shrinkage.
Sealed teeth should be monitored clinically every 6-12 months
and a radiograph is taken if indicated.
So after you write your treatment plan you should assign an
appointment for recall and follow up between 6-12 months
according to the caries risk of the patient.
Defective sealants should be investigated and a fresh sealant is
placed if you have lost some of the old FS or if there is marginal
leakage due to FS shrinkage…

PRR: Preventive Resin Restoration


CAR: Conservative Adhesive Restoration
PRR is a form of preventive restoration in a way that you restore
the carious tooth and prevent a future caries…
So you do a small pit and you restore it with composite and you
apply a FS on the top of carious fissure and the rest of the fissure
which is not carious.
So you do restoration to the carious fissures and prevent
caries on the non carious one.
In PRR, the word resin means that you’re placing resin inside
(composite).
====================
CAR: it’s the same meaning; conserving tooth structure and
prevention of future caries BUT you use any adhesive material not
necessary composite, you can use GI, RMGI, or compomer…

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Definition of PRR: is a preventive approach to restore caries
with acid etch composite resin (AECR) &FS on the surface as an
alternative to amalgam in young permanent molars.

The rationale for this procedure is to conserve tooth structure


and prevent future caries and you place it instead of amalgam
which doesn’t conserve tooth structure and doesn’t prevent future
caries and you are actually extending your cavity to retain amalgam
but in CAR you don’t need to do this.

The rationale is the most conservative approach in incipient


occlusal caries in young permanent teeth where carious lesion are
restored with minimum removal of dentin while ensuring
prevention of future caries in other pits and fissures at the same
surface through FS placement.

How did this procedure arise?


**By the advent of acid etch which eliminate “extension for
prevention” & reduced destruction of healthy tooth structure.
**concept of PRR expanded by rapid progress in development of
adhesive materials such as composite resin(CR), bonding agent,
GIC, and later on RMGI…
Cavity preparation is limited to removal and restoration with
CR, GIC, or combination of the two & FS on the surface.
===================

☻ Teeth which have minimal caries or questionable


carious lesion(you are not sure if the caries is deep or not so
you drill and if the caries is shallow then you place PRR).
☻ Traditionally in context of young permanent molars.
☻ Clinical diagnosis or suspect of fissure caries without
obvious or extensive cavitations of enamel.
===================

☻ Large carious occlusal caries you do class I filling but


not PRR.
☻ Large extensive occlusal caries or restorations whose
margins are extending interproximally.
If you have a proximal caries never ever say that I want to do PRR
you do class II filling.
The same thing applies to the anterior teeth if you have a class III
you don’t call it a PRR it’s a class III filling.

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So the PRR is a filling that is done for the occlusal surface of
posterior teeth or the facial or lingual pit for any tooth

We have 3 types of PRR based on the extent of the caries or the


depth of the cavity after removal of caries:
 Type I: caries removal is limited to enamel you can
restore it with (1) FS only or (2) CR & then FS on top of the
whole surface. But Dr prefers to place CR then FS.
No local anesthesia is required in this case because the cavity is
limited to enamel.
 Type II: is where incipient lesion has extended into
dentin but it’s small.
 Type III: also lesion is extended to dentin but it’s bigger
than class II.
In type II & III you have to place a liner which is usually
vitrabond (adhesive type of GI) then you place CR or GI or you
place vitramere(combination of GI & CR and it’s a type of RMGI)
and then FS is placed on top of the whole surface.
Questions from students:
Why we put a liner????
Because we reach the dentin and we want to seal the dentinal
tubules.
We use vitrabond as a liner we no longer use calcium hydroxide in
the clinic unless you have a direct pulp capping or some other
pulpal procedures.
How to differentiate between type III PRR and class I filling?
It’s not that much different but actually class I is deeper and some
times type III PRR is similar to class I; and in the clinic if you do a
class I and you do it in the sequence of PRR Dr will consider it PRR.

Type LA Extent Restoration

I No Enamel -FS
-CR & FS
II Yes Dentin -GIC & FS
(optional) (small) -GIC & CR & FS
III Yes Dentin -GIC & FS
(large) -GIC & CR & FS
Note that in both type II & III you can place GIC then CR then FS.

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There are 4 different combinations of materials used:
 FS
 CR & FS
 GIC & FS
 GIC & CR & FS
Also we have RMGI & compomer.
The choice of restoration depends on:
• Clinical and radiograph diagnosis.
• Size of the caries.
• Caries risk of the patient.
Look page 26, upper slide:
This is PRR-illustrated: we have a layer of GIC, then CR and on the
top of the whole surface FS
===================
Look to the lower one on the same page:
(B) In this case here is a buccal pit; sealing of this buccal pit is
essential
(C) There is extensive occlusal caries in 1st permanent molars it
could have been prevented with FS
Placement of GIC in PRR instead of CR has advantages &
disadvantages:
Advantages Disadvantages

-fluoride release especially in -decreased cohesive


high risk patient. strength ”the adhesion of
-it binds chemically to dentin the material to itself “
unlike CR to enamel (needs which means poor
micromechanical bonds) resistance to abrasion, a
-the coefficient of thermal low wear resistance(it’s a
expansion is similar to tooth. brittle material)
-biocompatible; not toxic to -long setting time
the pulp.
-minimum setting shrinkage
unlike composite.
Technique:
 You need cotton rolls, suction and the patient opens his
mouth.
 Investigate suspected lesion with small round bur (size
ss#1/4) never use a straight, fissure or diamond bur.
 After you have done your cavity you acid etch for 20
seconds then wash and dry.

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 Apply FS or CR+FS or GIC+CR+FS (when you apply
composite resin don’t forget to place a bonding agent, but in
case of glass ionomer you don’t need to place a bonding
agent).
 Adjust occlusion
Student asked why do we use round bur only?
Dr said because we want to prepare very small cavity and small
round bur is designed for this purpose.
Benefits of PRR:
1-conservative
2-esthetic alternative to amalgam.
3-prevention of caries.

***look page 28, lower slide:


Look how much tooth structure has been consumed; while
this amalgam restoration has been well placed it’s an inappropriate
restoration for a patient of 20 years whose only caries is an
incipient lesion on the occlusal surface.
This amalgam will weaken the marginal ridges and
supporting cusps and compromise the tooth in the long term, a
PRR would have been a much better choice.

 PRR is not limited to primary teeth; it can be done for


both dentitions.
 PRR is a very durable restoration, in a study they
compared PRR with amalgam they found both of their
effectiveness and durability was the same.
 PRR is any cavity on the occlusal surface or facial or
lingual pit; so if I have a labial pit on the incisor because of
hypoplasia I will do PRR for it.
 When you do a composite filling and PRR it’s the same
but the difference that in PRR we place a FS on the top of the
whole surface. So don’t go to the Dr and tell her that you’ve
done composite and FS you must say PRR.
 Never ever put composite on the fissure, you just
restore the cavity with it because the occlusion will be very
high. You just put FS on the fissure.
 When you do acid etching then washing and drying
then you place bonding agent then you put composite then
you place FS right away and cure it, BUT remember you must
maintain moisture control very well.

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 Fluoride was detected in human dental enamel in 1805
and waterborne fluoride was detected by Berzelius in 1822.
 Fluoride containing dentifrices (‫ )معجون السنان‬became
available at least as early as 1902.
 When ingested, fluoride is rapidly absorbed into plasma
from the gut.
 Peak plasma fluoride occurs within 1 hour of ingestion.
Salivary & gingival cervicular fluid levels also elevated &
provide topical effects on teeth either by direct contact when
drinking water for example, or by gingival cervicular fluid.
 Fluoride has a strong affinity for Ca salts especially
calcium phosphate crystals and becomes incorporated into
bone and teeth during dental development.
 Bone is the body’s major reservoir for fluoride
deposition not teeth.
 Fluoride is not immediately incorporated in hard tissue
and it’s rapidly excreted in urine and to a lesser degree in
sweat and feces.
 Fluoride continues to enter bone after development but
after teeth have been fully formed negligible amounts of
fluoride are incorporated by continued apposition of
cementum (root).
 Fluoride enters hard tissues by replacing hydroxyl
groups to form calcium fluorapatite.
 Fluoride effects on dental caries: 50% less dental caries
in areas where the drinking water contains about 1 ppm of
fluoride and is ingested throughout the period of dental
development compared with non fluoride areas.

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