Treatment Planning and Management of Orthodontic Problems










462 Part 4 The Transitional Years: Six to Twelve Years
of caries reduction from using sealants on permanent teeth
has been well documented, as decades worth of research
has shown clear evidence of a reduction in caries, and clini-
cal practice guidelines have been developed.
8,11
Wright et al.
provide a summary of the evidence of sealant ecacy in caries
reduction
13
:
e results of this systematic review suggest that children and
adolescents who receive sealants in sound occlusal surfaces or in
noncavitated pit-and-ssure carious lesions in their primary or
permanent molars (compared to a control without sealants) experi-
ence a 76% reduction in the risk of developing new carious lesions
after 2 years of follow up. Even after 7 or more years of follow-up,
children and adolescents with sealants had a caries incidence of
29%, whereas those without sealants had a caries incidence of
74%.
In addition, compared with teeth without sealants, teeth that
receive sealants are less likely to receive subsequent restorative
treatment. If restorative treatment is required, the time until the
rst restorative treatment is greater than that for unsealed molars,
and the restoration is likely to be less extensive.
14
e eectiveness of sealants in preventing caries is so well
recognized in the literature that a study design with a “sealant-free
control group is no longer considered ethically acceptable.
15
e
2016 Clinical Practice Guidelines of the American Dental Associa-
tion (ADA) recommend the use of sealants compared with nonuse
in permanent molars, and the strength of the recommendation
was strong, meaning that the evidence of caries reduction by sealants
was of moderate to high quality.
11
Given the long clinical history
and ample available literature as to their eectiveness, the expectation
would be that sealants would have been widely adopted by the
dental profession and utilized to their fullest preventive eect.
However,evenwith50years’worthofscienticknowledge,sealants
are still underused.
Current Sealant Utilization
In 1974, when sealants were new technology, the initial ADA
sealant utilization survey found that only 39% of dentists were
placing sealants.
16
While adhesive dentistry was making great
strides in acceptance for restorative procedures, utilizing sealants
forpreventionwasstilllow,andthusby1981theADAsCouncil
on Dental Materials, Instruments, and Equipment sponsored a
major conference with the title, “Pit and Fissure Sealants: Why
eirLimitedUsage?”Bythelate1980sand1990s,regionaland
national surveys indicated large increases in sealant utilization among
dentists.
17,18
Survey data suggest that 79% of dentists utilize sealants
in their practice “very often” or “often” in permanent teeth, while
53%rarely”ornever”usesealantsinprimaryteeth.
19
Regional
surveys indicate that most pediatric dentists (up to 96%) and
most recent graduates (90% of dentists in practice for 10 years or
less) utilize sealants.
18,20,21
However, despite the reported increased
incorporation of sealants into dentists’ practices, the number of
children receiving sealants is unexpectedly low.
Data from the NHANES for the years 2011 to 2012 suggest that
the prevalence of dental sealants on permanent teeth in children
aged 6 to 11 years was 41% and was 43% for adolescents aged 12
to 19 years.
3
Both of these gures are an increase from the 1999
to2004prevalenceat30%and38%,respectively.However,in
the low-income population, sealant use rates still remain low and
have been found to be 22% or lower.
22
Sealant rates were also
lowest in non-Hispanic black (30%) compared with non-Hispanic
• eprogressiveandcumulativeeectsofcariescontinueinto
adulthood, with 91% of adults experiencing caries. Just over
33% of adults aged 20 to 39 had experienced some tooth loss
(not including third molars), and 19% of seniors were
edentulous.
• Approximately20%ofchildrenaged6to8haduntreated
primarytoothdecay,and15%ofadolescentshaduntreated
caries in the permanent dentition.
While dental caries is common, the distribution of caries is
unequal, with certain subgroups of the population experiencing a
disproportionately greater burden of dental disease. According to
the National Institute for Dental and Craniofacial Research, 20%
of the population bears at least 60% of the caries.
5
Dental caries
is more prevalent among children living in poverty,
5a
with poor
children experiencing ve times more untreated dental caries than
children in higher income families.
6
Minority populations are also
vulnerable, as children of Mexican American and non-Hispanic
black ethnicities are more likely to experience severe and untreated
caries.
4,7
Moreover, the pattern of caries involving specic tooth
surfaces has changed. In the early 1970s, smooth surface lesions
accountedforalmost25%oftheDecayed,Missing,FilledSurfaces
(DMFS) index. Recent data indicate that approximately 90% of
caries in permanent teeth of children occur in pits and ssures,
and approximately two-thirds of caries are on the occlusal surface
alone.
8
Like permanent teeth, the pits and ssures of primary teeth
are also at risk, as roughly 44% of carious lesions in the primary
teeth aect the occlusal surfaces of molars.
8
e occlusal surface is prone to caries for several reasons. First,
newly erupted, immature tooth enamel has a relatively high organic
content and is more permeable, which makes it more susceptible
to caries attack. Second, the pit and ssure morphology provides
an environment for plaque retention and bacteria proliferation.
e enamel is thinner in pits and ssures and may experience
accelerated demineralization. In addition, the molars take a relatively
longtimetofullyerupt(1.5to2.5yearscomparedwithjustseveral
months for premolars).
9
is prolonged eruption time may interfere
with adequate oral hygiene, as toothbrush bristles have diculty
reaching the occlusal surface when it is out of the plane of occlusion,
and the operculum covering the distal portion of the tooth may
increase plaque retention.
10
In addition, uoride is less eective
in preventing caries on the occlusal surfaces compared with smooth
surfaces,
11
and data from uoridated communities show signicantly
higher reductions in interproximal lesions compared with pit and
ssure lesions.
12
Hence targeting preventive eorts at the occlusal
surfaces of molars is appropriate for attempting to decrease the
caries experience for US children.
Dental caries has aicted the human population for centuries,
and before the early 1970s, treatment consisted of removing the
carioustoothstructure.However,in1955,Buonocorerevolutionized
dentistry with the rst research on adhesive dentistry. From his
research came the idea that dentists might have the ability to bond
a physical barrier over susceptible pits and ssures and, in eect,
seal” out caries, preventing the carious process. In 1971 the rst
dental sealant, Nuva-Seal (L.D. Caulk), was introduced, and since
that time many studies have examined various products’ ability
to seal the occlusal surfaces of teeth to maximize “the power of
prevention.
Sealant Eectiveness
Unquestionably, dental sealants prevent pit and ssure caries
in both primary and permanent teeth. e long-term benet

CHAPTER 33 Pit and Fissure Sealants: Scientic and Clinical Rationale 463
made signicant strides in making sealants a covered benet. In
1991only58%ofMedicaidprogramsprovidedreimbursement,
butby1994 all50states includedsealants intheirMedicaid
programs.
21,27
However, only 12% provide reimbursement for
sealants on premolars, and 30% reimburse sealant application
only once per tooth per lifetime (thus not covering reapplica-
tion as necessary). Many studies are providing evidence that
sealant application in any teeth at risk for caries (primary and
permanent molars and premolars) is cost-eective and worthy of
reimbursement.
28–31
How Sealants Work
ree types of materials are utilized as sealants: resin, glass ionomer
(traditional and resin-modied), and polyacid-modied resins.
e most commonly accepted material is the resin-based sealant,
as it has shown superior retention rates compared with glass ionomer
sealants.
32–35
e resin-based sealant utilizes the principles of adhesive
dentistry as it is retained by micromechanical retention. For the
adhesion of the sealant to the enamel to be successful, the tooth
must be clean and remain dry because the resin is hydrophobic.
etoothenamelisetchedwith35%to37%phosphoricacid,
which creates surface irregularities in which the sealant material
ows and forms resin tags (Fig. 33.1). e resin is polymerized
(usually by visible light but there are also autopolymerizing resins)
and forms a thin, plastic coating over the pits and ssures of the
occlusal surface. is physical barrier is essential in preventing the
carious process (Fig. 33.2).
white (47%), Hispanic (40%), or non-Hispanic Asian (43%)
adolescents.
3
With the knowledge that by age 19 nearly 70% of
adolescents have experienced tooth decay and that 90% of these
caries occur in the pits and ssures, one might expect much higher
utilization rates.
Low utilization has been attributed to a lack of condence
in the bonding of sealants to enamel, concern for sealing over
caries, and the diculty of achieving isolation.
23
Survey data
indicate that dentists are apprehensive about sealing over incipient
caries,as80%ofrespondentsindicatethattheychoosenotto
seal over incipient caries.
24
Fear of placing a sealant over caries
was one of the most frequently voiced concerns in the surveys
comments section. is topic will be discussed in detail later in
this chapter.
Another signicant reason cited for limiting sealant usage is the
lack of reimbursement for sealant placement. Surveys reveal that
lack of insurance reimbursement for both initial placement and
reapplication is a frequently reported reason for limiting sealant
usage.
12,19
Concerning the lack of reimbursement, insurance
companies provide the following reasons
25,26
: (1) concerns about
cost-eectiveness of sealants; (2) sealants excluded in the original
or current contract; (3) guidelines for sealant placement are not
dened; and (4) potential for inappropriate usage and fees. However,
these reasons are not well founded. Of the insurance companies
that do provide sealant coverage, approximately two-thirds dene
certain clinical conditions for reimbursement such as age limita-
tions and restriction of sealant placement to permanent teeth,
with some specifying molars only.
12
Medicaid programs have
A B
C D
Figure 33.1 Effects of the acid-etch technique on surface morphology (scanning electron microscopy).
(A) The surface of sound enamel is relatively smooth, with occasional depressions representing termina-
tions of enamel prisms. Several different patterns of etching can occur: (B) the loss of prism cores following
etching; (C) the loss of prism peripheries following etching; (D) surface porosities occur, but without a
distinct prism morphologic appearance.

464 Part 4 The Transitional Years: Six to Twelve Years
Color
Sealants are often available as clear or opaque white. e advantages
to an opaque sealant are that it is easy to see during application
and easy to monitor its retention at a recall visit. Assessment of
a clear sealant requires tactile exploration of the sealed surface.
One study examining the visibility of clear and opaque sealants
found that the error rate for identifying an opaque sealant was
less than 2%, while for clear resin it was nearly 23%. e most
common error for the examiners was to incorrectly state that a
clear resin sealant was present on a tooth that had never been
treated.
39
No apparent dierence in the clinical ecacy of either
type of sealant has been reported. However, as will be discussed
later, sealant retention is critical for the caries preventive eect;
hence being able to quickly and correctly assess sealant retention
is clinically important.
One additional sealant material is available with color-changing
properties. Clinpro (3M ESPE, St. Paul, MN) is a sealant that
is pink upon application and turns white when cured. is color
change is not correlated with ensuring that the sealant is adequately
Glass ionomer sealants have a dierent bonding mechanism.
ey adhere to the enamel through both mechanical retention
and chemical bonding, known as chelation. However, the chemical
bond alone is weak. Glass ionomers are hydrophilic and can
withstand some minimal moisture. For the glass ionomer sealant,
the tooth is cleaned, and a tooth conditioner of polyacrylic acid
is applied. e tooth is rinsed and dried, and the glass ionomer
is placed on the occlusal surface. If it is a resin-modied glass
ionomer, it is light cured.
Types of Sealants
Sealant products come in a variety of materials, colors, and viscosi-
ties. Resin-based sealants are available as unlled, lled, clear,
colored, visible-light polymerized, autopolymerizing (chemically
cured), and uoride-releasing materials. e earliest sealants were
autopolymerizing but have largely been replaced by visible-light
curing sealants, though studies have shown similar retention rates
and similar strengths.
15,36–38
A
CD
B
Figure 33.2 The enamel-resin interface (scanning electron microscopy). (A) Following sealant place-
ment, the pits and ssures on this occlusal surface are protected from cariogenic challenges by the
physical barrier of the sealant. (B) The interface between the enamel forming the ssure and the sealant
appears to be an intimate one, with no apparent space between the etched enamel and sealant. (C)
Following partial demineralization of enamel that has been sealed, resin tags (arrows) may be seen in the
etched enamel. (D) Complete demineralization of enamel that has been sealed allows one to visualize the
appearance of the acid-resistant resin tags.

CHAPTER 33 Pit and Fissure Sealants: Scientic and Clinical Rationale 465
application. It is generally accepted that the eectiveness of sealants
depends on long-term retention,
62
and in clinical studies, retention
is considered the principal evaluation criteria, as it is used as a
surrogate measure of eectiveness in preventing caries.
38
When
compared with resin-based sealants, patients who receive glass
ionomer sealants have a ve times greater chance of experiencing
sealant loss at 2 to 3 years.
13
However, studies have shown that
while glass ionomer sealants are not retained as well, the caries
preventive eect is similar or superior to resin-based sealants.
13,63–65
Hence the panel of experts convened to write the 2016 Clini-
cal Practice Guidelines was unable to determine the superiority
of one type of sealant material over another due to low quality
of evidence.
11
If glass ionomer sealants have poor retention, how can they
still protect against caries? e theories for the protective benet
of glass ionomer material despite its poor retention rates are that
(1) the glass ionomer material remains in the deepest parts of the
ssures, still providing a physical barrier, even though it is not
clinically evident, or (2) the glass ionomer imparts a long-term
benet to the tooth such that the ssures are more resident to
demineralization. Studies suggest that the residual cariostatic
property of glass ionomer sealant is most likely due to a physical
barrier of remaining glass ionomer in the ssures rather than a
chemical eect on demineralization inhibition.
66–68
Glass ionomer sealants are widely used in countries with limited
access to dentistry as part of the atraumatic restorative treatment
(ART) technique. (See Chapter 22 for a discussion of ART.) Several
studies have shown the caries-preventive eect of ART sealants.
69–71
e technique for ART sealants is to apply a conventional, high
viscosity glass ionomer with “nger pressure” on a clean, dry tooth
that has been conditioned with polyacrylic acid.
70
High-viscosity
materials are better retained than those of low to medium
viscosity.
71
e panel of experts convened for the 2016 Clinical Practice
Guidelines were not able to provide specic recommendations for
the eectiveness of dierent sealant materials, since the evidence
of the head-to-head comparisons was of low quality. e panel
recommends choosing the type of material most appropriate for
particular clinical scenarios. For instance, when a child is cooperative
and the tooth can be adequately isolated, a resin-based sealant will
be better retained. However, if isolation is dicult or the tooth is
not fully erupted, or the child would benet from sealant placement
but has less than ideal cooperation, a glass ionomer may be more
appropriate.
11
Polyacid-Modied Resin Composites
(Compomers)
Polyacid-modied resin composites were introduced in the 1990s
as a new class of materials that aimed to combine the esthetic
property of composite with the uoride-releasing property and
adhesion of glass ionomer. ese materials have been nicknamed
compomers.” ey are similar to composite in that they contain
no water and are hydrophobic, set by a polymerization reaction,
lack the ability to bond to tooth structure, and require bonding
agents of the type used with conventional composite resins.
72
Like
glass ionomers, they do release uoride; however, their uoride
release levels are signicantly lower than those of glass ionomer
cements.
72
As a sealant material, polyacid-modied resin composites
underperform glass ionomer cements in terms of uoride release
and underperform conventional resin composite materials in terms
of retention.
73–75
cured and provides no clinical advantage. us the color-changing
property has been described as a “perceived marketing benet.
40
However, this material has similar properties to and is as caries-
protective as other resin-based sealants, and thus may be chosen
for its other properties (unlled, uoridated).
41,42
Filler Content
Sealants also are available with various ller content. For the most
part, the ller content dictates the sealant’s physical characteristics
regarding viscosity, ow ability, and resistance to wear. Unlled
sealants have some advantages. Unlled sealants have lower rates
of microleakage
43,44
and better penetration into the ssures.
45,46
e
theory is that unlled sealants penetrate deeper into the ssures
due to their low viscosity, create longer resin tags, and therefore are
better retained. However, unlled and lled sealants have similar
retention rates.
47,48
Another clear advantage of the unlled sealant
is that occlusal adjustment is not necessary. Due to the lack of
ller, the unlled sealant will abrade rapidly if left in occlusion.
On the other hand, lled sealants require occlusal adjustment, as
individuals are not able to abrade occlusal interferences caused by
lled sealants to a comfortable level.
49
e necessity to adjust the
occlusion may increase the time and cost of the procedure and
may also prevent delegation of sealant placement to auxiliaries.
40,50
On the other hand, lled materials have greater wear resistance
and less porosity. In fact, several studies have examined owable
composite as a sealant material. Flowable composite requires
the use of a bonding agent that improves ssure penetration
and decreases microleakage.
51,52
For clinical retention, owable
composite is equal to
53
and possibly superior to conventional
sealant materials.
54
However, the superiority of any type of sealant
material remains inconclusive.
13
e dentist should understand
the properties of sealant materials and choose a material for its
clinical advantages.
Fluoride-Releasing Sealants
55
Based on the knowledge of the benets of uoride release from
glass ionomer materials, dental manufacturers have also developed
uoride-releasing resin sealants (FRS). However, studies have shown
that salivary uoride levels are the same before and after sealant
placement, and there is no long-lasting release of uoride to plaque
and saliva.
56,57
One should not consider uoride-containing sealants
as a uoride reservoir with long-term release of uoride into the
immediately adjacent environment.
38
Clinical studies have not
demonstrated signicant caries prevention of FRS over the benets
obtained from conventional sealants.
58
Only one randomized
controlled trial has shown a cariostatic eect of FRS on the distal
surface of adjacent primary molars
59
; however, the percentage of
new decayed or lled surfaces at 30 months follow-up was so
small that it may not indicate a true clinical signicance.
60
Studies
are contradictory as to the inferiority of retention rates of FRS
compared with those of conventional sealants.
38,58,61
Given that the
evidence is inconclusive as to the benet of sealants containing
uoride, dentists should not choose a sealant material based on
this property.
Glass Ionomer
Glass ionomer cement sealants were introduced as an alterna-
tive to resin-based sealants based on their uoride releasing and
recharging ability, their higher moisture toleration, and their easy

466 Part 4 The Transitional Years: Six to Twelve Years
e theory was that the occlusal surface was most vulnerable to
caries within the rst few years after eruption and that the risk
of developing caries after this time period dropped dramatically.
However, longitudinal data from the postuoridation era show
new carious lesions develop yearly.
82,83
In1988Ripaetal.analyzed
data from nearly 2000 children aged 10 to 13 years who were
examined annually for 3 years to determine caries activity. e
authors found that the occlusal surfaces of molars suered relatively
constant attack between ages 10 and 16, at a rate of 10.4% per
year.
82
New information indicates that uorides may have caused
a delay in pit and ssure caries, resulting in occlusal surfaces that
decay at a later age.
84
Hence the nature of primary caries is chang-
ing from a rapidly progressing disease of childhood to a slowly
progressing disease that commences in childhood but progresses
steadily in adulthood.
84
In accordance, the evidence-based recom-
mendations endorse that adults as well as children should receive
sealants when the tooth or the patient is at risk of experiencing
caries.
8
e question of whether to place a sealant over a ssured
surface should not be based on how long ago the tooth erupted
but on the clinical impression of whether a sealant is necessary
to prevent caries. Fig. 33.4 is a decision-making tree for sealant
placement and can be utilized to help dentists decide when to
apply sealants.
Which Teeth Should Be Sealed?
Traditionally, noncarious rst and second permanent molars with
deep ssures were the candidates for sealants; however, recom-
mendations have been extended to any tooth at risk of developing
caries, including primary teeth; permanent molars with incipient,
noncavitated lesions; and/or premolars.
8
At-risk primary teeth
benet from sealant placement, as resin-based sealants are retained
wellonprimarymolars,withretentionratesinthe70%to95%
range at approximately 3 years.
85,86
Glass ionomer cements are not
retained well and are not recommended for use as sealant material
on primary teeth.
87
Given the preventive benet to the primary
molar, when the child is able to cooperate for sealant placement,
sealants should be utilized.
8
e indications for sealant placement include: (1) deep, retentive
pits and ssures, which may cause wedging or catching of an
Who Really Needs Sealants?
Caries Risk Assessment
Caries management emphasizes the need for caries risk assessment,
which is the likelihood of the incidence of caries during a certain
time period. It is important to analyze the risk of caries for an
individual during the decision-making process for sealants. Placing
ssure sealants should not be considered “routine” for all children,
as low-risk teeth receive little benet from sealant placement,
76,77
and it is not cost-eective.
29,78
Not only should the patient be
evaluated for caries risk, but the tooth itself should be evaluated
as well. Heller and colleagues studied caries progression in sound
teeth with and without sealants and in teeth with incipient carious
lesions (dened by dark staining of the grooves, chalky appearance,
or a slight explorer catch; Fig. 33.3) with and without sealants.
ese researchers found that the preventive benet for sealing
soundteethwasonly4.5%,whilesealingoverincipientcaries
lowered the caries incidence by 41%, almost a 10-fold dierence.
77
erefore sealants are indicated when the dentist determines that
the tooth or the patient is at risk of experiencing caries.
8
Sealant Versus Fluoride Varnish: Which Is More
Likely to Reduce Occlusal Caries?
Fluoride varnish reduces caries in permanent teeth.
79
Along with
reducing the incidence of smooth surface lesions, varnish has also
been shown to reduce pit and ssure caries.
80,81
Fluoride varnish
may be eective for pit and ssure caries because it adheres to the
deeper part of the ssures for a long period of time allowing a
high uptake of uoride ions.
80
However, when compared against
each other, sealants are more eective in reducing the incidence
of caries. When compared with varnish, sealants would still reduce
the incidence of caries by 34%.
11
Hence the 2016 Clinical Practice
Guideline recommends the use of sealants compared with varnish.
11
Age at Placement
Previousstudiesfromthe1950sand1960sshoweda peakin
caries incidence occurring shortly after eruption and then tapering.
AB
Figure 33.3 Examples of early, noncavitated incipient caries. The premolar exhibits distinct, dark brown
early caries (A), while the molar exhibits white demineralization around the pits and ssures and light
brown discoloration within the pits and ssures (B). Both of these teeth would be candidates for sealants
and would not require mechanical preparation prior to sealant placement.

CHAPTER 33 Pit and Fissure Sealants: Scientic and Clinical Rationale 467
possibility of adequate isolation from salivary contamination. us
if placing a sealant is clinically indicated on any tooth with pit
and fissures, a sealant should be utilized to prevent caries
development.
Contraindications for sealant placement include: (1) well-
coalesced, self-cleaning pits and ssures; (2) radiographic or clinical
evidence of interproximal caries in need of restoration; (3) the
presence of many interproximal lesions or restorations with no
preventive plan/treatment to inhibit caries formation; (4) limited
lifeexpectancyoftheprimarytooth; and(5)nopossibilityof
adequate isolation from salivary contamination either due to
eruption status or patient behavior.
Diagnosing Occlusal Caries
Diagnosing occlusal caries can be dicult, and research has shown
that dentists correctly diagnosis occlusal caries in only 42% of
cases.
88
In2005Stookeychallengedthelong-heldbeliefthatprobing
an occlusal groove with an explorer was necessary to diagnose a
carious lesion.
89
He summarized the evidence, which suggests that
the use of an explorer does not increase dentists’ ability to make
a correct diagnosis, and forceful use of an explorer can damage
the tooth. Dentists are just as likely to make a correct diagnosis
of a dry tooth in terms of the presence or absence of caries using
only visual inspection as they are when utilizing an explorer.
88
Proponents of eliminating the use of an explorer raise the concern
that not only is tactile examination unreliable, but forceful explorer
usage can cause enamel defects, resulting in possible caries develop-
ment or progression by causing cavitation of a previously non-
cavitated lesion.
90–92
In one study, a dentist was asked to gently
probe a sample of third molars, half of which had initial carious
explorer(Fig.33.5);(2)stainedpitsandssureswithminimal
appearance of decalcication or opacication (i.e., incipient caries
with no cavitation; see Fig. 33.3); (3) no radiographic or clinical
evidence of interproximal caries in need of restoration on teeth to
be sealed; (4) use of other preventive treatment, such as uoride
therapy,toinhibitinterproximalcariesformation;and(5)the
Caries risk
assessment
Tooth Status
Caries free or
incipient caries with
no cavitation?
No interproximal
caries?
Place transitional
glass ionomer
sealant
OR
Monitor and place
on recall
Isolation Status
Operculum is at or
below the marginal
ridge?
Tooth can be
adequately isolated?
Deep, retentive
grooves?
Stained grooves?
Incipient caries?
Evaluate for
restoration
Place
sealant
Patient Cooperation
Patient can
cooperate for
sealant procedure
Tooth Status
Caries free?
Well-coalesced
grooves?
No treatment;
institute preventive plan
and regular recall
High/moderate
Minimal/preventive
Yes
Yes
Yes
Yes
No
No
No
Yes
No, caries
No,
caries
Evaluate for
restoration
Figure 33.4 Flow chart to aid in making decisions about sealant placement.
Figure 33.5 Molar with deep, retentive grooves, an ideal candidate for
sealant placement—especially since the patient has existing stainless steel
crown restorations that indicate a high caries risk assessment.

468 Part 4 The Transitional Years: Six to Twelve Years
What is the science behind this decision? If sealants are applied
properly and are monitored periodically, caries arrest beneath a
sealant, as demonstrated by numerous studies.
42,94–98
Oong et al.
found that sealing over noncavitated lesions reduced the probability
of lesion progression by more than 70%.
99
What is the scientic
rationale for this nding? Sealants signicantly reduce the bacteria
levelsinlesionsbecause(1)acidetchingaloneeliminates75%of
the viable microorganisms
100
and (2) retained sealant deprive bacteria
of access to nutrients; bacteria which persist under sealants cannot
produce acid when isolated from carbohydrate substrate, and thus
progression of the lesion is unlikely.
99
In a recent review of six
studies that addressed the reduction in viable bacteria after sealant
placement, the authors found that sealing caries was associated
with a 100-fold reduction in mean total viable bacteria counts.
99
Despite the recommendation by experts to seal over noncavitated
occlusal surfaces,
11,93
many dentists in the United States are reluctant
to seal carious teeth, as they are concerned that the caries will
progress underneath the sealant.
101,102
Fontana et al. addressed
this barrier to sealant utilization in a recent a study in which
the authors sealed noncavitated lesions with a clear sealant and
monitored these lesions with visual inspection, radiography, and
laser uorescence.
42
e use of radiography and laser uorescence
added objective ways to measure caries progression, since visual
inspection can be subjective. After almost 4 years of follow-up,
sealantsthatwerereappliedyearlyasneededandwere98%eective
in preventing progression of lesions (Fig. 33.6). is study is part
of the rapidly growing body of high-quality evidence emphasizing
the power of the sealant.
However, practitioners who are concerned about sealing over
caries will often decide to take an invasive approach by prepping
the tooth “just in case.” Some will erroneously call this a “preventive
resin restoration” (PRR) when, in fact, it is most likely a ssurotomy
or enameloplasty procedure. e PRR is more appropriately termed
the conservative adhesive resin restoration. (See Chapter 22 for
a detailed discussion of conservative adhesive restorations.) e
most contemporary denition of a PRR (conservative adhesive
restoration) is that one area (pit/ssure) of the occlusal surface
has a lesion that is cavitated and extends to dentin while the rest
of the surface remains noncavitated or caries-free. An example
of this would be a permanent maxillary rst molar where the
distal pit of the occlusal surface is carious but the central pit and
radiating ssures remain caries-free. In this instance, the distal
lesions and half of which had sound occlusal surfaces.
92
e teeth
were then extracted and the ssures were examined with a scanning
electron microscope. Enamel defects were noted for all of the teeth
with initial caries and for two of the sound surfaces. Forceful use
of an explorer in demineralized ssures can, in essence, cause
cavitation by creating an entrance through which cariogenic
microorganisms can penetrate into the softened substructure.
91
Opponents of the explorer do not endorse eliminating the explorer
altogether. ey recommend that the explorer be used dierently,
mainly to eliminate plaque in the ssures and to determine surface
roughness of incipient lesions
89
: “e tip of the explorer should
be moved gently across the surface of any non-cavitated area to
determine the presence or absence of surface roughness as an
indication of whether the underlying demineralized area reects
an active lesion.
e concept of using moderate, rm pressure to nd a “catch
in the ssure is no longer the most contemporary approach to
caries diagnosis and management. e use of explorers is not
necessary for the detection of early lesions, since it does not improve
the validity of the diagnosis of ssure caries, and visual examination
of a clean, dry tooth is sucient to detect early lesions.
8,88
Several
new technologies have shown promise to aid in caries diagnosis
and in caries monitoring over time: light-induced and infrared
laser uorescence devices, the electronic caries detector, quantitative
laser uorescence, and transillumination. However, to date, no
technology can substitute for a thorough visual exam and clinical
judgment based on experience.
Sealing Over Incipient Caries
A paradigm shift has occurred in the management of carious
lesions. One hundred and fty years ago, complete removal of
all traces of caries was the gold standard; however, advances in
theeldofcariologyhavechallengedthisperspective.In2015,a
group of cariology experts from around the world convened for
the International Caries Consensus Collaboration (ICCC), which
reported the groups clinical recommendations for carious tissue
removal and cavity management. e experts agree that a tooth
should not be restored surgically until the lesion is cavitated and into
dentin. Hence early lesions—ones that are in enamel or just into
dentin and are noncavitated—should be managed through biolm
removal (i.e., toothbrushing) and/or remineralization or by sealing
over them.
93
Baseline Pre-Sealant
(0-months)
ICDAS 4; x-ray D1
Diagnodent 52
(Taken with Suni
camera)
Post-Sealant
(12-months)
ICDAS 4; x-ray D1
Diagnodent 45
(Taken with Digidoc
camera)
Post-Sealant
(24-months)
ICDAS 4; x-ray D1
Diagnodent 59
(Taken with Digidoc
camera)
Post-Sealant
(44-months)
ICDAS 4; x-ray D1
Diagnodent 52
(Taken with Digidoc
camera)
Figure 33.6 Sealed carious permanent molars monitored over 44 months. ICDAS, International Caries
Detection and Assessment System. (From Fontana M, Platt JA, Eckert GJ, et al. Monitoring of sound
and carious surfaces under sealants over 44 months. J Dent Res. 2014;93:1070–1075.)

CHAPTER 33 Pit and Fissure Sealants: Scientic and Clinical Rationale 469
recommended clinical management.
41
As one can appreciate, surgical
intervention is much further down the continuum than likely
indicated by the training of many practitioners in the United
States. In summary, unless the lesion is a cavitated, dentin carious
lesion, it should be sealed.
93
Preparing the Tooth for a Sealant
Cleaning the Tooth
For a resin-based sealant to ow into the ssures of the tooth, the
ssures must be free of debris. Several methods have been suggested
for cleaning the ssures. Historically it has been advocated to clean
the tooth with pumice slurry and a prophy cup or bristle brush;
however, other cleaning methods have been shown to be eective.
Debris can be cleaned using an explorer through the ssures and
forcefully rinsing with air-water spray
38
or with a dry bristle
toothbrush.
103
A recent clinical study showed improved retention
with the pumice slurry and rubber cup cleaning method.
104
Complete debridement of the ssures is very dicult, and as a
result complete penetration of the sealant rarely occurs with
conventional cleaning methods.
105,106
A superior cleaning method
is the utilization of an air-polishing system such as a Prophy Jet,
as it removes more debris than conventional methods (Fig.
33.8).
107,108
is in turn allows greater sealant penetration and an
increased number of resin tags for micromechanical retention.
109–111
Despite these advantages, air-polishing most likely never became
the standard for pit and ssure sealant application, due to the
increased equipment cost and complexity of the procedure without
signicantly improved retention rates.
40,112
Mechanical Preparation
Minimally invasive techniques have been described to improve
the penetration and retention of ssure sealants. e ssurotomy
pit is opened, caries is removed, and intact pit and ssures are
not opened with a bur. A restorative material (composite, glass
ionomer, amalgam) is placed in the distal pit cavity prep, and sealant
is utilized over the remaining intact pits and ssures. Hence the
preventive” portion of the “PRR” is placing sealant over intact
but susceptible pits and ssures. e PRR (conservative adhesive
restoration), when utilized as discussed previously, is an excellent
restoration, especially if the sealant is reapplied as needed. However,
it cannot be overemphasized that mechanical preparation of a
noncavitated lesion is not necessary. Once a permanent tooth has
been restored, it begins the cycle of restoration. e restoration
will likely be replaced several times during that persons life, and
repeated restorations may compromise the survival of the tooth
itself. Fig. 33.7 is a diagram of the continuum of caries and the
Primary prevention at the
patient level
Caries risk assessment at the patient level
No
disease
ICDAS 0
Initial
lesion
ICDAS 1
Initial
lesion
ICDAS 2
Moderate
lesion
ICDAS 3
Moderate
lesion
ICDAS 4
Extensive
lesion
ICDAS 5
Extensive
lesion
ICDAS 6
Staging
of lesion
severity
Additional
information
that informs
diagnosis
Caries lesion activity assessment
Radiographs and other diagnostic aids
Caries risk assessment at the tooth surface level
DIAGNOSIS
No
treatment
Remineralize Arrest Sealant Minimal
surgical
Traditional
surgical
Endodontic
treatment
Extraction
Secondary prevention Tertiary prevention (care)
Figure 33.7 Caries diagnosis and management system continuum. ICDAS, International Caries Detec-
tion and Assessment System. (From Zero DT, Zandona AF, Vail MM, Spolnik KJ. Dental caries and pulpal
disease. Dent Clin North Am. 2011;55:29–46.)
Figure 33.8 The Cavitron Prophy Jet. (Courtesy DENTSPLY Profes-
sional, York, PA.)

470 Part 4 The Transitional Years: Six to Twelve Years
In addition, as discussed earlier, sealant can be placed over incipient,
noncavitated lesions without removal of tooth structure. ere is
a signicant volume of evidence of high sealant retention without
the use of a bur.
Eect of a Recent Professionally Applied
Fluoride Treatment
Dentists might note the need for sealant placement or sealant
repair at a patients dental exam and would like to complete the
procedures the same day. However, many patients receive a pro-
phylaxis and uoride application prior to their dental exam. Hence
the concern that uoride might inhibit or decrease sealant bond
strength has been explored. Multiple studies conrm that sealant
bond strengths and retention rates are not aected by a topical
uoride gel or foam treatment prior to sealant application.
131–133
If a patient has had a gel or foam application, the practitioner
need not delay sealant application or repair. However, many oces
exclusively use uoride varnish. For these practitioners, the teeth
should be examined and sealed prior to the application of varnish
(Box 33.1).
Factors Aecting Sealant Success
Etchant
Etchants are available as separate phosphoric acid etchants, self-
etching systems, liquids, and gels. Historically the clinical sealant
procedure involved an etching time of 60 seconds and a rinsing
time of at least 10 seconds. However, multiple studies have shown
similar bond strengths for both permanent and primary teeth,
withloweretchingtimesof15to30seconds.
134–137
Etching time
should be increased for uorotic teeth. e usual recommendation
and enameloplasty techniques involve utilizing a small bur to remove
any residual debris and/or dubious enamel tissue as well as to
widen the ssure, leading to increased enamel surface and improved
penetration of the sealant into the ssure.
113
In lab studies, the
enameloplasty allows deeper sealant penetration and better adapta-
tion as well as increases the surface area for acid etching,
114,115
but
studies conict as to whether the technique decreases microleakage.
43
While one recent systematic review concluded that a preparation
method before ssure sealant application can increase sealant
retention, the review included a number of dierent preparation
methods besides a bur, including cleaning the ssure with a rubber
cup, air abrasion, and the use of a carbon dioxide laser.
113
When
examining the use of a bur only, the literature is conicting regarding
any clinical benet from mechanical preparation. Several studies
have reported increased retention of sealants after mechanical
preparation of the ssures,
116–119
while other studies have not shown
a superior retention rate or enhanced performance of the
sealant.
120–123
A limited number of studies have shown that air
abrasion in combination with acid-etching results in improved
retention of sealants
124–126
; however, air abrasion alone cannot be
a substitute for acid etching.
127–129
Other disadvantages to invasive techniques are that mechanical
preparation limits the delegation of sealant placement to auxiliaries,
which decreases cost-eectiveness, and opening the ssures by bur
preparation can predispose the teeth to caries after sealant loss.
113
e European Academy of Pediatric Dentistry summarizes the
evidence well in its guidelines that state: “purposeful removal of
enamel or enameloplasty just to widen the base of a ssure in a
sound tooth is an invasive technique, which disturbs the equilibrium
of the ssure system and exposes a child unnecessarily to the use
of a handpiece or air abrasion.
130
ey conclude that plaque should
be removed in order to obtain sucient bonding, but that the
removal of tooth structure by a bur is unnecessary and undesirable.
Isolation
Isolation should be achieved by any of the methods previously mentioned. The
most common method of isolation is the cotton roll method, as described by
Waggoner and Siegal
140
:
The patient is in a supine position with the head extended back and the
chin up because this improves visibility and moisture control.
For maxillary isolation: a triangular buccal isolation shield, such as a
Dri-Angle (Fig. 33.12), is placed against the buccal mucosa over the Stensen
duct with the apex of the triangle directed posteriorly. A cotton roll may be
placed in the maxillary vestibule to hold the tissue away from the tooth. The
mouth mirror is used throughout the entire procedure and should be left in
position throughout the procedure until polymerization of the sealant is
achieved. Besides providing indirect vision, this will also act as a shield for the
tongue.
For mandibular isolation: Cotton rolls are placed on both the buccal and
lingual sides of the teeth. A cotton roll holder may be utilized or the rolls may
be held in place with the ngers. Waggoner and Siegal advocate utilizing a
triangular isolation shield as a tongue shield by bending the apex of the
triangular shield at a right angle (Fig. 33.13). This bend is placed between the
lingual cotton roll and the alveolar ridge so that the larger portion of the shield
rests on the tongue. This prevents the tongue from pushing saliva over the
lingual cotton roll. Changing cotton rolls or adding additional cotton rolls is
unnecessary. Excess moisture can be evacuated from the area with the high
volume evacuation suction. Utilizing a four-handed delivery method will
increase the success of achieving adequate isolation.
Etching
Once isolated, the tooth is etched, most commonly with 37% phosphoric acid.
The etchant can be applied liberally and should ow onto all of the susceptible
pits and ssures, including lingual grooves of maxillary molars and buccal pits
of mandibular molars (Fig. 33.14). The etchant should extend up the cuspal
line angles, 2 to 3 mm beyond the anticipated margin of the sealant. The
etchant should remain on the surface for 15 to 20 seconds.
Rinsing and Drying
The tooth should be rinsed utilizing the air-water spray and high volume
suction. The goal of rinsing is to remove all of the etchant from the tooth
surface. The tooth should then be thoroughly dried until the surface appears
chalky or frosted (see Fig. 33.9A and B). Unlike dentin bonding, in which
the collagen brils should remain moist to prevent collapsing, the enamel
keeps its crystalline structure. This means that the enamel should be
thoroughly dried or desiccated to maximize the penetration of the hydrophobic
sealant. The tooth must remain dry and uncontaminated from this point
forward.
Sealant Application and Polymerization
If a bonding agent is to be used, it should be applied with a microbrush. The
bonding agent should be lightly dried and cured. The sealant should be applied
to all pits and ssures, including the lingual grooves of maxillary molars and
the buccal pits of mandibular molars (Fig. 33.15). The sealant may be applied
with a variety of instruments: an explorer tip, a PICH instrument (a calcium
The Clinical Procedure BOX 33.1

CHAPTER 33 Pit and Fissure Sealants: Scientic and Clinical Rationale 471
Curing
e polymerization process begins when photoinitiators, most
commonly camphoroquinone, absorb energy from blue light with
a wavelength in the region of 470 nanometers.
147
is absorption
facilitates the conversion of low-viscosity monomer units into a
polymer matrix. A sealant must be adequately cured in order for
it to obtain its purported physical properties. If the curing time
is insucient, the bonding is poor, and decreases in hardness may
result, leading to subsequent sealant failure.
148
Several types of curing lights are available (see Chapter 21).
e traditional unit is the quartz tungsten halogen (QTH) curing
light unit. ese units require a fan for cooling, are relatively
low-cost, are easy to maintain and repair if a bulb needs replacement,
anddeliverenergydensityoutputsof400to800mW/cm
2
. ey
have largely been replaced by light-emitting diode (LED) curing
lights. LED curing lights have changed dramatically in the past
decade, and units continue to oer increasing intensity.
149
In general,
higher energy output means that curing time can be shortened
(from 40 seconds for QTH to 20 seconds with a higher powered
LED for 2 mm of composite).
150,151
Some of the highest powered
LEDs on the market oer outputs of 1000 to more than 3000
mW/cm
2
of energy and usually have “turbo,” “boost,” or “plasma
modes that oer very high energy outputs in very small increments
oftime,like5seconds.
Not much literature has been published either conrming or
challenging recommended curing times for sealants. Most manu-
facturers recommend a 20-second exposure time. However, one
must consider which kind of curing light is being utilized, as not
all perform equally. One study has found that 20 seconds of curing
for rinsing is 20 to 30 seconds. A few studies have shown that a
shorter rinse time yields similar enamel bond strengths as a
20-second rinse time.
138,139
Hence the exact rinse time is not as
important as ensuring that the rinse is thorough enough to remove
all of the etchant from the surface.
140
e dierent forms of etchant (i.e., gel or liquid) have been
shown to perform similarly in regard to penetration, bond strength,
and clinical retention.
135,141,142
On the other hand, dierent types
of etchants do not provide similar results. Self-etching systems
yield signicantly lower bond strengths than separate etch systems
and exhibit much lower retention rates in clinical trials, as reported
in a recent systematic review (highest level of evidence).
143
Self-
etching systems have decreased bond strengths on uncut enamel.
144
Utilizing a self-etching bonding system without the use of a separate
etch step is not recommended.
8,143
Drying Agents and Time
Given the hydrophobic nature of resins, drying agents such as
alcohol or acetone have been explored as possible treatments
after the etchant step, before sealant placement. However, a
laboratory study showed that the use of drying agents did
not decrease microleakage or increase sealant penetration.
145
Furthermore, one clinical investigation showed no signicant
improvements of retention rates with the use of drying agents.
146
ere is no recommended drying time. Rather, a specic
result should be obtained. e occlusal surface should have
a chalky or frosted appearance (Fig. 33.9). If this result is
not obtained after thorough drying, the tooth should be
re-etched.
hydroxide, or Dycal, placer), or a small brush. Many manufacturers offer
their own delivery system, which may consist of a preloaded syringe with
a small tip so that the sealant can be applied directly from the syringe to
the tooth. The sealant should not be overlled, to ensure that the sealant
material does not extend past the etched area, to limit the amount of occlusal
interference created, and to ensure optimal depth of cure. If overlling occurs,
the excess material may be removed with a small brush. If small bubbles
form within the sealant material, these should be teased out before
polymerization. Once the sealant has been satisfactorily placed, the curing
light tip should be placed as closely as possible to the surface, and the
sealant should be cured for the amount of time recommended by the
manufacturer, which is usually 20 seconds with an light-emitting diode
curing light that has an output of 800 to 1000 mW/cm
2
. The operator should
understand which type of curing light is being used and how its energy
output can affect the exposure time. As mentioned previously, very short
curing times are insufcient to achieve optimal cure, especially of opaque
sealants.
Evaluating the Sealant
Once the sealant has been cured, the operator should visually and tactilely
examine the sealant before removing the isolation materials. If the operator
discovers bubbles, voids, or areas of decient material, material can be
directly added at this time because the oxygen inhibited layer has not been
disturbed. The sealant’s retention should also be evaluated by attempting to
dislodge the sealant with an explorer. If material de-bonds, the ssure should
be inspected for remaining debris. The area should be re-etched, rinsed, dried,
and new sealant material applied. If some of the sealant pooled over the distal
marginal ridge, a ledge may have been created that should be removed. Also,
if any sealant material was misplaced into the interproximal areas, it should be
removed. Most likely the excess material can be removed with an explorer or
scaler. The unpolymerized layer should be removed by rubbing the surface
with pumice on a cotton roll or by rinsing the surface for 30 seconds to limit
the patient’s exposure to bisphenol-A.
Depending on the sealant material type, the occlusion may require
adjustment. Filled sealants and owable composite used as sealant require
adjustment, whereas unlled sealants abrade quickly and are considered to be
“self-adjusting.” The occlusion can be adjusted with the use of a round
composite nishing bur in the high-speed handpiece or with a stone or round
bur in the slow speed handpiece.
Periodic Evaluation
Sealants should be evaluated at every recall visit. Retention of the sealant
material is critical to its success. Partial or complete loss of a sealant results
in a surface that is equally at risk for caries as one that had never been
sealed. One-time sealant placement does not impart any long-term protection
unless the physical barrier over the ssure, the sealant, remains intact. Loss of
the sealant in any groove or pit renders that pit or ssure susceptible to caries
attack. Therefore sealants should be maintained and repaired or replaced as
needed. If a sealant partially remains, attempts can be made to try to dislodge
the remaining material with an explorer. If it remains intact, there is no need to
remove the material with a handpiece. The tooth may be cleaned with pumice
and a rubber cup, and the usual sealant application steps can be followed,
etching both the enamel and remaining sealant and then applying additional
material.
The Clinical Procedure—cont’d BOX 33.1

472 Part 4 The Transitional Years: Six to Twelve Years
cannot be completely removed by rinsing.
159
e acid etch step
creates microporosities in the enamel, and if saliva touches the
tooth, these porosities are occluded so the sealant cannot form
resin tags to micromechanically bond to the tooth. Achieving
adequate isolation is a critical step to the success of the sealant
and is considered a key concept in the clinical procedure
(Box 33.2).
160
Several studies have shown that cotton roll isolation is comparable
to rubber dam isolation.
116,161,162
However, a recent systematic review
has shown that retention is increased when rubber dam isolation
is utilized (Fig. 33.10).
38
In addition, vacuum systems such as the
Vac-Ejector and Isolite have been shown to produce sealant retention
rates comparable to those placed under cotton roll and rubber
dam isolation.
163–166
(See Chapter 22 for a discussion of isolation
systems.) Whenever possible, especially if concurrent operative
AB
Figure 33.9 (A) Etched enamel displaying frosted appearance. (B) Note the demarcation between the
chalky, etched enamel (arrow) and the shiny unetched enamel of the buccal surface.
Sealant placement is very technique-sensitive. If sealant material de-bonds
upon immediate evaluation, one of the following three causes is the most
likely culprit:
1. Debris remains in the ssure. The tooth must be clean. If plaque or organic
debris remains in the ssure, the resin cannot ow into the ssure to form
tags and micromechanically bond to the enamel. Clean the ssures with a
rubber cup and pumice, re-etch, and complete the application steps again.
2. Saliva contaminated the enamel. If isolation was not meticulously
maintained and saliva contacted the occlusal surface, then saliva pooled in
the microporosities created by the etchant step. Even if the operator
noticed the saliva contamination and decided to dry the tooth again, the
viscous saliva cannot be removed by rinsing alone. Thus the resin sealant
will “oat” on the saliva and cannot form resin tags. In this case, the tooth
should be re-etched, dried, and resealed with no saliva contamination.
3. The tooth was not completely dry after the rinsing step. If the tooth does
not appear chalky after an adequate etching time, it is most likely not dry.
Enamel bonding is different from dentin adhesion. In restorative dentistry,
one is advised not to desiccate the dentin; however, enamel needs to be
absolutely dry prior to sealant application. If water remains in the etched
enamel pores, the hydrophobic resin will “oat” on top of the water and
not form resin tags. Again, no micromechanical bonding will occur, and the
sealant will de-bond when evaluated with an explorer.
Troubleshooting Sealant Placement BOX 33.2
with a traditional QTH light is insucient to cure resin-based
sealants to a clinically adequate depth.
147
Two in vitro studies have
examined the depth of cure of dental sealant with LED units that
oer high energy and very short curing times, and found these
very short curing times to be inadequate to optimally cure dental
sealant, especially opaque material.
152,153
Several factors aect the
level of cure, including shade of the material, the ller content,
the thickness of the material, the intensity of the curing light,
and the distance of the light source from the material.
154
Opaque
shades, though white in color, behave more like materials in the
dark shade range because they are not translucent, so light does
not pass through them easily to cure deeper areas of the material.
Hence clear sealants can be cured to a deeper level than opaque
sealants given similar curing times.
147,153
More research is necessary
to determine the appropriate balance between saving chair time
with faster curing and still obtaining clinically sucient physical
properties of resin materials. Clinicians should ensure optimal
curing by using a high-intensity light source, placing the light
tip as close as possible to the sealant and maximizing the curing
duration.
In addition to ensuring an optimal cure, a practitioner might
be able to improve retention of the sealant by delaying polymerization
for several seconds after sealant application, assuming scrupulous
isolation can be maintained. A study by Chosack and Eidelman
found that the longer sealants were allowed to remain on the
etchedsurface beforepolymerization (20seconds vs.5 or10
seconds), the more sealant material penetrated into microporosities,
creating longer resin tags, which are critical for micromechanical
retention.
155
Isolation
Resin-based sealants are moisture-sensitive. Saliva contamination
signicantly lowers bond strengths because it prevents the formation
of resin tags that alter mechanical retention and thus results in
decreased retention.
156–158
At times, practitioners who are placing
sealants will notice that a small amount of saliva seeps onto the
tooth from the tongue or the cotton roll, and the practitioner
erroneously believes that if the tooth is rinsed and dried well, the
sealant retention will not be aected. However, even minimal
exposure to saliva results in the formation of a surface coating that

CHAPTER 33 Pit and Fissure Sealants: Scientic and Clinical Rationale 473
wet dentin. Utilizing a layer of bonding agent between the enamel
and hydrophobic resin sealant has been studied to determine if
this additional step could enhance retention rates. Numerous
laboratory studies have found decreased microleakage and enhanced
penetration of sealant material into the ssures with the adjunct
of a bonding agent.
170–174
A recent systematic review and meta-
analysis (highest level of evidence) examined ve studies that met
inclusion criteria. Results of the meta-analysis indicated that adhesive
systems beneath ssure sealants had a signicant positive benet
on retention and thus caries prevention.
175
e authors note that
the positive eect was seen in studies that used fth-generation
bonding agents (those that require a separate etch and rinse step
but have the “prime” and “bond” together as one step). It seems
that the smaller molecular size of the adhesive components,
compared with the sealant components, penetrate better into enamel
porosities, and this improves bond strength. Not only do permanent
teeth benet from the adjunct of a bonding agent, but studies are
also favorable for primary teeth; they also show similar laboratory
results to that of permanent teeth with increased bond strengths
and decreased microleakage when a bonding agent is utilized.
176,177
e use of a bonding agent should only be utilized with hydrophobic
resin-based sealant materials. Glass ionomers chemically bond to
the enamel, so utilizing a bonding agent under this material is not
logical.
Another advantage of utilizing a bonding agent is noted for
hypomineralized permanent molars, which often present a chal-
lenge for the dentist regarding adhesive dentistry. ese teeth
often have enamel defects and are at higher risk for eventually
needing restorative treatment compared with “normal” teeth.
178
Hence these teeth are excellent candidates for preventive eorts.
However, research has shown that hypomineralized teeth need
to be retreated with sealant application after a much shorter
time period than teeth in the control group.
179
e addition of
a bonding agent with sealant application in hypomineralized
teeth can increase ssure sealant retention compared with acid
etching alone.
180
Even though recent systematic review shows a positive eect
for the use of a bonding agent, there are two main disadvantages
to this technique. Utilizing a bonding agent increases the cost of
the procedure and increases chair time.
40
Several studies have found
this step to be unnecessary,
47,181–183
and they highlight the importance
of proper sealant placement technique: fastidious isolation and
proper placement negate the need for this additional step. However,
a bonding agent should be used when “in the opinion of the dental
professional, the bonding agent would enhance sealant retention
in the clinical situation.
8
Auxiliary Application
Well-trained dental auxiliaries are procient at the application
of pit and ssure sealants. As early as 1976, Stiles et al. reported
no dierence in the retention of the sealant when applied by a
dentist or a trained dental auxiliary.
184
Since then, several studies
have examined sealant placement by auxiliaries and found high
retention rates.
185–188
In addition, delegating sealant application is
cost-eective and results in increased sealant usage.
185
In studies
addressing sealant longevity by operator, researchers found that
proper education of personnel and following up on each individuals
aptitude in sealant placement are essential, as “individual operator
rather than provider type is highly sensitive to sealant success or
failure.
189,190
Hence both dental assistants and dental hygienists
are as procient in sealant application as the dentist, and the
treatment is provided, rubber dam isolation should be used.
However, given the discomfort that can be associated with rubber
dam placement on nonanesthetized tissues, rubber dam isolation
is not imperative as long as the operator can maintain a dry eld
with alternative techniques.
Timing of Sealant Placement
e timing of sealant placement has been known to correlate with
the overall retention of the sealant, as studies have shown that
partially erupted teeth require repair or replacement more often
than fully erupted teeth.
167
Dennison et al. concluded that when
the operculum of the gingiva extended over the distal marginal
ridgeofthetooth,morethan50%oftheteethhadtoberesealed
due to sealant loss within 36 months; when the operculum was
at the level of the marginal ridge, retreatment fell to 26%.
168
Except
for high-risk children, sealant placement should be delayed until
the gingival tissues are at or below the marginal ridge.
140
For partially
erupted teeth, which are at high risk for experiencing caries, the
best practice is to place a sealant and repair or replace it as necessary.
Utilizing a bonding agent for these teeth under the sealant may
be benecial.
169
Alternatively, the sealant in this scenario may be
a glass ionomer sealant if the practitioner has diculty achieving
adequate isolation.
8
Not only should tooth eruption be considered when deciding
when to place a sealant, but a child’s level of cooperation must
also be considered. e child must be able to tolerate the isolation
method and the length of the procedure to place a successful
sealant. If the child is unable or unwilling to cooperate for the
procedure, placing sealants should be delayed until the level of
cooperation is adequate, or if the child has high caries risk, an
ART sealant with a glass ionomer could be used as a transitional
sealant.
Use of Intermediate Bonding Agent
Resin-based dental sealants are hydrophobic. Due to this property,
they cannot stand even slight moisture contamination. Dentinal
bonding agents have hydrophilic properties so that they can inltrate
Figure 33.10 Rubber dam isolation can be single tooth or quadrant
depending on the needs of the patient and will assist the practitioner in
keeping saliva from contaminating any of the ssures once they have been
etched.

474 Part 4 The Transitional Years: Six to Twelve Years
outer third of dentin). ese treatments are signicantly more
eective at arresting lesions compared with other preventive methods
like uoride varnish or recommending ossing.
195
Sealing Restorations
Given the caries preventive eect of sealant application, researchers
have examined other uses for sealants, such as increasing restoration
longevity by sealing over the restoration, repairing the margins of
restorations, and preventing enamel demineralization (“white spot
lesions”) around orthodontic brackets (Fig. 33.11). Several studies
have shown that restoration longevity can be increased by sealant
application along the margins of both composite and amalgam
restorations.
94,196,197
In 1998,Mertz-Fairhurst etal. compared
conventional amalgams to both sealed amalgam restorations and
to sealed composite restorations placed over frank caries without
caries removal (only a 1-mm bevel was placed around the lesion
in intact enamel).
94
In the 10-year follow-up, they found that the
conventional amalgam restorations had the highest occurrence of
open margins and the highest rate of recurrent caries, while the
sealed amalgams had the best outcomes with only one clinical
failure noted in the entire group. Considering that sealing over
restorations signicantly reduces microleakage, one would expect
sealed restorations to show decreased incidences of recurrent caries.
198
literature supports the delegation of sealant application to qualied
personnel.
Four-Handed Delivery
No clinical trials have addressed the two-handed versus four-handed
delivery on the retention of pit and ssure sealants. However, expert
opinion supports the use of a trained dental assistant or auxiliary
during sealant placement.
191
Having an assistant during sealant appli-
cation may improve the quality and eciency of sealant placement,
improve isolation, shorten placement time, reduce operator fatigue,
and enhance patient care.
191
Grin et al. found a positive association
for four-handed delivery and increased retention rates; however,
this is considered indirect evidence and is weaker than randomized
controlled trials.
191
Nevertheless, given this positive association, when
possible, sealants should be applied with the assistance of trained
personnel.
8
School-Based Sealant Programs
School-based sealant programs have been developed to increase
sealant usage to reduce caries and to provide prevention services
to children less likely to receive dental care, such as those children
from minority or low-income backgrounds. In 2001, the Centers
for Disease Control and Prevention (CDC) created a Task Force
to review the scientic evidence of the ecacy of school-based
programs. Based on ndings that the median caries reduction was
60% for children aged 6 through 17 years, the Task Force endorsed
school-based sealant programs in 2002.
192
School-based sealant
programs can (1) help serve low-income children who are at high
risk of developing caries and are less likely than their higher-income
counterparts to have a dental visit, (2) connect participating students
with sources of dental care in the community, and (3) enroll eligible
children in public insurance programs.
193
However, despite the
CDC’sTaskForceendorsement,in2013only15stateshadprograms
in more than half of schools where most students were low
income.
194
A recent economic analysis reported that providing
sealantsinschoolprogramsto1000childrenwouldprevent485
llings,toothachesforayearin133children,and1.59disability-
adjusted life-years. School-based sealant programs save society
money and remain cost-eective.
194
ey are “an important and
eective public health approach that complements clinical care
systems in promoting the oral health of children and
adolescents.
193
Other Uses for Sealant
Interproximal Dental Sealant
Two techniques can be utilized for sealing interproximal lesions,
which have been termed “microinvasive” interventions. e rst
is to use ssure sealant material with the etch and rinse technique.
If the lesion is visible, such as the mesial of a permanent rst molar
when the second primary molar exfoliates, the sealant can be directly
applied. Otherwise, orthodontic separators are placed, and the
material is applied at a later date when the teeth are separated and
the lesion is visible. e second technique is to utilize a resin
inltration system, such as ICON (DMG America, Englewood,
NJ). (See Chapter 40 for a more detailed discussion of the tech-
nique.) A recent Cochrane systematic review concluded that
microinvasive treatments (i.e., interproximal sealants) arrest
noncavitated enamel and early dentinal lesions (limited to the
Figure 33.11 Generalized demineralization after orthodontic treatment.
(From Cobourne MT, DiBiase AT. Handbook of Orthodontics. Edinburgh:
Mosby; 2010.)
Figure 33.12 Dri-Angle isolation shield. (Courtesy Dental Health Prod-
ucts, Inc., Niagara Falls, NY.)

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462 Part 4 The Transitional Years: Six to Twelve Yearsof caries reduction from using sealants on permanent teeth has been well documented, as decades worth of research has shown clear evidence of a reduction in caries, and clini-cal practice guidelines have been developed.8,11 Wright et al. provide a summary of the evidence of sealant ecacy in caries reduction13:e results of this systematic review suggest that children and adolescents who receive sealants in sound occlusal surfaces or in noncavitated pit-and-ssure carious lesions in their primary or permanent molars (compared to a control without sealants) experi-ence a 76% reduction in the risk of developing new carious lesions after 2 years of follow up. Even after 7 or more years of follow-up, children and adolescents with sealants had a caries incidence of 29%, whereas those without sealants had a caries incidence of 74%.In addition, compared with teeth without sealants, teeth that receive sealants are less likely to receive subsequent restorative treatment. If restorative treatment is required, the time until the rst restorative treatment is greater than that for unsealed molars, and the restoration is likely to be less extensive.14e eectiveness of sealants in preventing caries is so well recognized in the literature that a study design with a “sealant-free” control group is no longer considered ethically acceptable.15 e 2016 Clinical Practice Guidelines of the American Dental Associa-tion (ADA) recommend the use of sealants compared with nonuse in permanent molars, and the strength of the recommendation was strong, meaning that the evidence of caries reduction by sealants was of moderate to high quality.11 Given the long clinical history and ample available literature as to their eectiveness, the expectation would be that sealants would have been widely adopted by the dental profession and utilized to their fullest preventive eect. However,evenwith50years’worthofscienticknowledge,sealantsare still underused.Current Sealant UtilizationIn 1974, when sealants were new technology, the initial ADA sealant utilization survey found that only 39% of dentists were placing sealants.16 While adhesive dentistry was making great strides in acceptance for restorative procedures, utilizing sealants forpreventionwasstilllow,andthusby1981theADA’sCouncilon Dental Materials, Instruments, and Equipment sponsored a major conference with the title, “Pit and Fissure Sealants: Why eirLimitedUsage?”Bythelate1980sand1990s,regionalandnational surveys indicated large increases in sealant utilization among dentists.17,18 Survey data suggest that 79% of dentists utilize sealants in their practice “very often” or “often” in permanent teeth, while 53%“rarely”or“never”usesealantsinprimaryteeth.19 Regional surveys indicate that most pediatric dentists (up to 96%) and most recent graduates (90% of dentists in practice for 10 years or less) utilize sealants.18,20,21 However, despite the reported increased incorporation of sealants into dentists’ practices, the number of children receiving sealants is unexpectedly low.Data from the NHANES for the years 2011 to 2012 suggest that the prevalence of dental sealants on permanent teeth in children aged 6 to 11 years was 41% and was 43% for adolescents aged 12 to 19 years.3 Both of these gures are an increase from the 1999 to2004prevalenceat30%and38%,respectively.However,inthe low-income population, sealant use rates still remain low and have been found to be 22% or lower.22 Sealant rates were also lowest in non-Hispanic black (30%) compared with non-Hispanic • eprogressiveandcumulativeeectsofcariescontinueintoadulthood, with 91% of adults experiencing caries. Just over 33% of adults aged 20 to 39 had experienced some tooth loss (not including third molars), and 19% of seniors were edentulous.• Approximately20%ofchildrenaged6to8haduntreatedprimarytoothdecay,and15%ofadolescentshaduntreatedcaries in the permanent dentition.While dental caries is common, the distribution of caries is unequal, with certain subgroups of the population experiencing a disproportionately greater burden of dental disease. According to the National Institute for Dental and Craniofacial Research, 20% of the population bears at least 60% of the caries.5 Dental caries is more prevalent among children living in poverty,5a with poor children experiencing ve times more untreated dental caries than children in higher income families.6 Minority populations are also vulnerable, as children of Mexican American and non-Hispanic black ethnicities are more likely to experience severe and untreated caries.4,7 Moreover, the pattern of caries involving specic tooth surfaces has changed. In the early 1970s, smooth surface lesions accountedforalmost25%oftheDecayed,Missing,FilledSurfaces(DMFS) index. Recent data indicate that approximately 90% of caries in permanent teeth of children occur in pits and ssures, and approximately two-thirds of caries are on the occlusal surface alone.8 Like permanent teeth, the pits and ssures of primary teeth are also at risk, as roughly 44% of carious lesions in the primary teeth aect the occlusal surfaces of molars.8e occlusal surface is prone to caries for several reasons. First, newly erupted, immature tooth enamel has a relatively high organic content and is more permeable, which makes it more susceptible to caries attack. Second, the pit and ssure morphology provides an environment for plaque retention and bacteria proliferation. e enamel is thinner in pits and ssures and may experience accelerated demineralization. In addition, the molars take a relatively longtimetofullyerupt(1.5to2.5yearscomparedwithjustseveralmonths for premolars).9 is prolonged eruption time may interfere with adequate oral hygiene, as toothbrush bristles have diculty reaching the occlusal surface when it is out of the plane of occlusion, and the operculum covering the distal portion of the tooth may increase plaque retention.10 In addition, uoride is less eective in preventing caries on the occlusal surfaces compared with smooth surfaces,11 and data from uoridated communities show signicantly higher reductions in interproximal lesions compared with pit and ssure lesions.12 Hence targeting preventive eorts at the occlusal surfaces of molars is appropriate for attempting to decrease the caries experience for US children.Dental caries has aicted the human population for centuries, and before the early 1970s, treatment consisted of removing the carioustoothstructure.However,in1955,Buonocorerevolutionizeddentistry with the rst research on adhesive dentistry. From his research came the idea that dentists might have the ability to bond a physical barrier over susceptible pits and ssures and, in eect, “seal” out caries, preventing the carious process. In 1971 the rst dental sealant, Nuva-Seal (L.D. Caulk), was introduced, and since that time many studies have examined various products’ ability to seal the occlusal surfaces of teeth to maximize “the power of prevention.”Sealant EectivenessUnquestionably, dental sealants prevent pit and ssure caries in both primary and permanent teeth. e long-term benet CHAPTER 33 Pit and Fissure Sealants: Scientic and Clinical Rationale 463 made signicant strides in making sealants a covered benet. In 1991only58%ofMedicaidprogramsprovidedreimbursement,butby1994 all50states includedsealants intheirMedicaidprograms.21,27 However, only 12% provide reimbursement for sealants on premolars, and 30% reimburse sealant application only once per tooth per lifetime (thus not covering reapplica-tion as necessary). Many studies are providing evidence that sealant application in any teeth at risk for caries (primary and permanent molars and premolars) is cost-eective and worthy of reimbursement.28–31How Sealants Workree types of materials are utilized as sealants: resin, glass ionomer (traditional and resin-modied), and polyacid-modied resins. e most commonly accepted material is the resin-based sealant, as it has shown superior retention rates compared with glass ionomer sealants.32–35 e resin-based sealant utilizes the principles of adhesive dentistry as it is retained by micromechanical retention. For the adhesion of the sealant to the enamel to be successful, the tooth must be clean and remain dry because the resin is hydrophobic. etoothenamelisetchedwith35%to37%phosphoricacid,which creates surface irregularities in which the sealant material ows and forms resin tags (Fig. 33.1). e resin is polymerized (usually by visible light but there are also autopolymerizing resins) and forms a thin, plastic coating over the pits and ssures of the occlusal surface. is physical barrier is essential in preventing the carious process (Fig. 33.2).white (47%), Hispanic (40%), or non-Hispanic Asian (43%) adolescents.3 With the knowledge that by age 19 nearly 70% of adolescents have experienced tooth decay and that 90% of these caries occur in the pits and ssures, one might expect much higher utilization rates.Low utilization has been attributed to a lack of condence in the bonding of sealants to enamel, concern for sealing over caries, and the diculty of achieving isolation.23 Survey data indicate that dentists are apprehensive about sealing over incipient caries,as80%ofrespondentsindicatethattheychoosenottoseal over incipient caries.24 Fear of placing a sealant over caries was one of the most frequently voiced concerns in the survey’s comments section. is topic will be discussed in detail later in this chapter.Another signicant reason cited for limiting sealant usage is the lack of reimbursement for sealant placement. Surveys reveal that lack of insurance reimbursement for both initial placement and reapplication is a frequently reported reason for limiting sealant usage.12,19 Concerning the lack of reimbursement, insurance companies provide the following reasons25,26: (1) concerns about cost-eectiveness of sealants; (2) sealants excluded in the original or current contract; (3) guidelines for sealant placement are not dened; and (4) potential for inappropriate usage and fees. However, these reasons are not well founded. Of the insurance companies that do provide sealant coverage, approximately two-thirds dene certain clinical conditions for reimbursement such as age limita-tions and restriction of sealant placement to permanent teeth, with some specifying molars only.12 Medicaid programs have A BC D• Figure 33.1 Effects of the acid-etch technique on surface morphology (scanning electron microscopy). (A) The surface of sound enamel is relatively smooth, with occasional depressions representing termina-tions of enamel prisms. Several different patterns of etching can occur: (B) the loss of prism cores following etching; (C) the loss of prism peripheries following etching; (D) surface porosities occur, but without a distinct prism morphologic appearance. 464 Part 4 The Transitional Years: Six to Twelve YearsColorSealants are often available as clear or opaque white. e advantages to an opaque sealant are that it is easy to see during application and easy to monitor its retention at a recall visit. Assessment of a clear sealant requires tactile exploration of the sealed surface. One study examining the visibility of clear and opaque sealants found that the error rate for identifying an opaque sealant was less than 2%, while for clear resin it was nearly 23%. e most common error for the examiners was to incorrectly state that a clear resin sealant was present on a tooth that had never been treated.39 No apparent dierence in the clinical ecacy of either type of sealant has been reported. However, as will be discussed later, sealant retention is critical for the caries preventive eect; hence being able to quickly and correctly assess sealant retention is clinically important.One additional sealant material is available with color-changing properties. Clinpro (3M ESPE, St. Paul, MN) is a sealant that is pink upon application and turns white when cured. is color change is not correlated with ensuring that the sealant is adequately Glass ionomer sealants have a dierent bonding mechanism. ey adhere to the enamel through both mechanical retention and chemical bonding, known as chelation. However, the chemical bond alone is weak. Glass ionomers are hydrophilic and can withstand some minimal moisture. For the glass ionomer sealant, the tooth is cleaned, and a tooth conditioner of polyacrylic acid is applied. e tooth is rinsed and dried, and the glass ionomer is placed on the occlusal surface. If it is a resin-modied glass ionomer, it is light cured.Types of SealantsSealant products come in a variety of materials, colors, and viscosi-ties. Resin-based sealants are available as unlled, lled, clear, colored, visible-light polymerized, autopolymerizing (chemically cured), and uoride-releasing materials. e earliest sealants were autopolymerizing but have largely been replaced by visible-light curing sealants, though studies have shown similar retention rates and similar strengths.15,36–38ACDB• Figure 33.2 The enamel-resin interface (scanning electron microscopy). (A) Following sealant place-ment, the pits and ssures on this occlusal surface are protected from cariogenic challenges by the physical barrier of the sealant. (B) The interface between the enamel forming the ssure and the sealant appears to be an intimate one, with no apparent space between the etched enamel and sealant. (C) Following partial demineralization of enamel that has been sealed, resin tags (arrows) may be seen in the etched enamel. (D) Complete demineralization of enamel that has been sealed allows one to visualize the appearance of the acid-resistant resin tags. CHAPTER 33 Pit and Fissure Sealants: Scientic and Clinical Rationale 465 application. It is generally accepted that the eectiveness of sealants depends on long-term retention,62 and in clinical studies, retention is considered the principal evaluation criteria, as it is used as a surrogate measure of eectiveness in preventing caries.38 When compared with resin-based sealants, patients who receive glass ionomer sealants have a ve times greater chance of experiencing sealant loss at 2 to 3 years.13 However, studies have shown that while glass ionomer sealants are not retained as well, the caries preventive eect is similar or superior to resin-based sealants.13,63–65 Hence the panel of experts convened to write the 2016 Clini-cal Practice Guidelines was unable to determine the superiority of one type of sealant material over another due to low quality of evidence.11If glass ionomer sealants have poor retention, how can they still protect against caries? e theories for the protective benet of glass ionomer material despite its poor retention rates are that (1) the glass ionomer material remains in the deepest parts of the ssures, still providing a physical barrier, even though it is not clinically evident, or (2) the glass ionomer imparts a long-term benet to the tooth such that the ssures are more resident to demineralization. Studies suggest that the residual cariostatic property of glass ionomer sealant is most likely due to a physical barrier of remaining glass ionomer in the ssures rather than a chemical eect on demineralization inhibition.66–68Glass ionomer sealants are widely used in countries with limited access to dentistry as part of the atraumatic restorative treatment (ART) technique. (See Chapter 22 for a discussion of ART.) Several studies have shown the caries-preventive eect of ART sealants.69–71 e technique for ART sealants is to apply a conventional, high viscosity glass ionomer with “nger pressure” on a clean, dry tooth that has been conditioned with polyacrylic acid.70 High-viscosity materials are better retained than those of low to medium viscosity.71e panel of experts convened for the 2016 Clinical Practice Guidelines were not able to provide specic recommendations for the eectiveness of dierent sealant materials, since the evidence of the head-to-head comparisons was of low quality. e panel recommends choosing the type of material most appropriate for particular clinical scenarios. For instance, when a child is cooperative and the tooth can be adequately isolated, a resin-based sealant will be better retained. However, if isolation is dicult or the tooth is not fully erupted, or the child would benet from sealant placement but has less than ideal cooperation, a glass ionomer may be more appropriate.11Polyacid-Modied Resin Composites (Compomers)Polyacid-modied resin composites were introduced in the 1990s as a new class of materials that aimed to combine the esthetic property of composite with the uoride-releasing property and adhesion of glass ionomer. ese materials have been nicknamed “compomers.” ey are similar to composite in that they contain no water and are hydrophobic, set by a polymerization reaction, lack the ability to bond to tooth structure, and require bonding agents of the type used with conventional composite resins.72 Like glass ionomers, they do release uoride; however, their uoride release levels are signicantly lower than those of glass ionomer cements.72 As a sealant material, polyacid-modied resin composites underperform glass ionomer cements in terms of uoride release and underperform conventional resin composite materials in terms of retention.73–75cured and provides no clinical advantage. us the color-changing property has been described as a “perceived marketing benet.”40 However, this material has similar properties to and is as caries-protective as other resin-based sealants, and thus may be chosen for its other properties (unlled, uoridated).41,42Filler ContentSealants also are available with various ller content. For the most part, the ller content dictates the sealant’s physical characteristics regarding viscosity, ow ability, and resistance to wear. Unlled sealants have some advantages. Unlled sealants have lower rates of microleakage43,44 and better penetration into the ssures.45,46 e theory is that unlled sealants penetrate deeper into the ssures due to their low viscosity, create longer resin tags, and therefore are better retained. However, unlled and lled sealants have similar retention rates.47,48 Another clear advantage of the unlled sealant is that occlusal adjustment is not necessary. Due to the lack of ller, the unlled sealant will abrade rapidly if left in occlusion. On the other hand, lled sealants require occlusal adjustment, as individuals are not able to abrade occlusal interferences caused by lled sealants to a comfortable level.49 e necessity to adjust the occlusion may increase the time and cost of the procedure and may also prevent delegation of sealant placement to auxiliaries.40,50 On the other hand, lled materials have greater wear resistance and less porosity. In fact, several studies have examined owable composite as a sealant material. Flowable composite requires the use of a bonding agent that improves ssure penetration and decreases microleakage.51,52 For clinical retention, owable composite is equal to53 and possibly superior to conventional sealant materials.54 However, the superiority of any type of sealant material remains inconclusive.13 e dentist should understand the properties of sealant materials and choose a material for its clinical advantages.Fluoride-Releasing Sealants55Based on the knowledge of the benets of uoride release from glass ionomer materials, dental manufacturers have also developed uoride-releasing resin sealants (FRS). However, studies have shown that salivary uoride levels are the same before and after sealant placement, and there is no long-lasting release of uoride to plaque and saliva.56,57 One should not consider uoride-containing sealants as a uoride reservoir with long-term release of uoride into the immediately adjacent environment.38 Clinical studies have not demonstrated signicant caries prevention of FRS over the benets obtained from conventional sealants.58 Only one randomized controlled trial has shown a cariostatic eect of FRS on the distal surface of adjacent primary molars59; however, the percentage of new decayed or lled surfaces at 30 months follow-up was so small that it may not indicate a true clinical signicance.60 Studies are contradictory as to the inferiority of retention rates of FRS compared with those of conventional sealants.38,58,61 Given that the evidence is inconclusive as to the benet of sealants containing uoride, dentists should not choose a sealant material based on this property.Glass IonomerGlass ionomer cement sealants were introduced as an alterna-tive to resin-based sealants based on their uoride releasing and recharging ability, their higher moisture toleration, and their easy 466 Part 4 The Transitional Years: Six to Twelve Yearse theory was that the occlusal surface was most vulnerable to caries within the rst few years after eruption and that the risk of developing caries after this time period dropped dramatically. However, longitudinal data from the postuoridation era show new carious lesions develop yearly.82,83In1988Ripaetal.analyzeddata from nearly 2000 children aged 10 to 13 years who were examined annually for 3 years to determine caries activity. e authors found that the occlusal surfaces of molars suered relatively constant attack between ages 10 and 16, at a rate of 10.4% per year.82 New information indicates that uorides may have caused a delay in pit and ssure caries, resulting in occlusal surfaces that decay at a later age.84 Hence the nature of primary caries is chang-ing from a rapidly progressing disease of childhood to a slowly progressing disease that commences in childhood but progresses steadily in adulthood.84 In accordance, the evidence-based recom-mendations endorse that adults as well as children should receive sealants when the tooth or the patient is at risk of experiencing caries.8 e question of whether to place a sealant over a ssured surface should not be based on how long ago the tooth erupted but on the clinical impression of whether a sealant is necessary to prevent caries. Fig. 33.4 is a decision-making tree for sealant placement and can be utilized to help dentists decide when to apply sealants.Which Teeth Should Be Sealed?Traditionally, noncarious rst and second permanent molars with deep ssures were the candidates for sealants; however, recom-mendations have been extended to any tooth at risk of developing caries, including primary teeth; permanent molars with incipient, noncavitated lesions; and/or premolars.8 At-risk primary teeth benet from sealant placement, as resin-based sealants are retained wellonprimarymolars,withretentionratesinthe70%to95%range at approximately 3 years.85,86 Glass ionomer cements are not retained well and are not recommended for use as sealant material on primary teeth.87 Given the preventive benet to the primary molar, when the child is able to cooperate for sealant placement, sealants should be utilized.8e indications for sealant placement include: (1) deep, retentive pits and ssures, which may cause wedging or catching of an Who Really Needs Sealants?Caries Risk AssessmentCaries management emphasizes the need for caries risk assessment, which is the likelihood of the incidence of caries during a certain time period. It is important to analyze the risk of caries for an individual during the decision-making process for sealants. Placing ssure sealants should not be considered “routine” for all children, as low-risk teeth receive little benet from sealant placement,76,77 and it is not cost-eective.29,78 Not only should the patient be evaluated for caries risk, but the tooth itself should be evaluated as well. Heller and colleagues studied caries progression in sound teeth with and without sealants and in teeth with incipient carious lesions (dened by dark staining of the grooves, chalky appearance, or a slight explorer catch; Fig. 33.3) with and without sealants. ese researchers found that the preventive benet for sealing soundteethwasonly4.5%,whilesealingoverincipientcarieslowered the caries incidence by 41%, almost a 10-fold dierence.77 erefore sealants are indicated when the dentist determines that the tooth or the patient is at risk of experiencing caries.8Sealant Versus Fluoride Varnish: Which Is More Likely to Reduce Occlusal Caries?Fluoride varnish reduces caries in permanent teeth.79 Along with reducing the incidence of smooth surface lesions, varnish has also been shown to reduce pit and ssure caries.80,81 Fluoride varnish may be eective for pit and ssure caries because it adheres to the deeper part of the ssures for a long period of time allowing a high uptake of uoride ions.80 However, when compared against each other, sealants are more eective in reducing the incidence of caries. When compared with varnish, sealants would still reduce the incidence of caries by 34%.11 Hence the 2016 Clinical Practice Guideline recommends the use of sealants compared with varnish.11Age at PlacementPreviousstudiesfromthe1950sand1960sshoweda peakincaries incidence occurring shortly after eruption and then tapering. AB• Figure 33.3 Examples of early, noncavitated incipient caries. The premolar exhibits distinct, dark brown early caries (A), while the molar exhibits white demineralization around the pits and ssures and light brown discoloration within the pits and ssures (B). Both of these teeth would be candidates for sealants and would not require mechanical preparation prior to sealant placement. CHAPTER 33 Pit and Fissure Sealants: Scientic and Clinical Rationale 467 possibility of adequate isolation from salivary contamination. us if placing a sealant is clinically indicated on any tooth with pit and fissures, a sealant should be utilized to prevent caries development.Contraindications for sealant placement include: (1) well-coalesced, self-cleaning pits and ssures; (2) radiographic or clinical evidence of interproximal caries in need of restoration; (3) the presence of many interproximal lesions or restorations with no preventive plan/treatment to inhibit caries formation; (4) limited lifeexpectancyoftheprimarytooth; and(5)nopossibilityofadequate isolation from salivary contamination either due to eruption status or patient behavior.Diagnosing Occlusal CariesDiagnosing occlusal caries can be dicult, and research has shown that dentists correctly diagnosis occlusal caries in only 42% of cases.88In2005Stookeychallengedthelong-heldbeliefthatprobingan occlusal groove with an explorer was necessary to diagnose a carious lesion.89 He summarized the evidence, which suggests that the use of an explorer does not increase dentists’ ability to make a correct diagnosis, and forceful use of an explorer can damage the tooth. Dentists are just as likely to make a correct diagnosis of a dry tooth in terms of the presence or absence of caries using only visual inspection as they are when utilizing an explorer.88 Proponents of eliminating the use of an explorer raise the concern that not only is tactile examination unreliable, but forceful explorer usage can cause enamel defects, resulting in possible caries develop-ment or progression by causing cavitation of a previously non-cavitated lesion.90–92 In one study, a dentist was asked to gently probe a sample of third molars, half of which had initial carious explorer(Fig.33.5);(2)stainedpitsandssureswithminimalappearance of decalcication or opacication (i.e., incipient caries with no cavitation; see Fig. 33.3); (3) no radiographic or clinical evidence of interproximal caries in need of restoration on teeth to be sealed; (4) use of other preventive treatment, such as uoride therapy,toinhibitinterproximalcariesformation;and(5)theCaries riskassessmentTooth StatusCaries free orincipient caries withno cavitation?No interproximalcaries?Place transitionalglass ionomersealantORMonitor and placeon recallIsolation StatusOperculum is at orbelow the marginalridge?Tooth can beadequately isolated?Deep, retentivegrooves?Stained grooves?Incipient caries?Evaluate forrestorationPlacesealantPatient CooperationPatient cancooperate forsealant procedureTooth StatusCaries free?Well-coalescedgrooves?No treatment;institute preventive planand regular recallHigh/moderateMinimal/preventiveYesYesYesYesNoNoNoYesNo, cariesNo,cariesEvaluate forrestoration• Figure 33.4 Flow chart to aid in making decisions about sealant placement. • Figure 33.5 Molar with deep, retentive grooves, an ideal candidate for sealant placement—especially since the patient has existing stainless steel crown restorations that indicate a high caries risk assessment. 468 Part 4 The Transitional Years: Six to Twelve YearsWhat is the science behind this decision? If sealants are applied properly and are monitored periodically, caries arrest beneath a sealant, as demonstrated by numerous studies.42,94–98 Oong et al. found that sealing over noncavitated lesions reduced the probability of lesion progression by more than 70%.99 What is the scientic rationale for this nding? Sealants signicantly reduce the bacteria levelsinlesionsbecause(1)acidetchingaloneeliminates75%ofthe viable microorganisms100 and (2) retained sealant deprive bacteria of access to nutrients; bacteria which persist under sealants cannot produce acid when isolated from carbohydrate substrate, and thus progression of the lesion is unlikely.99 In a recent review of six studies that addressed the reduction in viable bacteria after sealant placement, the authors found that sealing caries was associated with a 100-fold reduction in mean total viable bacteria counts.99Despite the recommendation by experts to seal over noncavitated occlusal surfaces,11,93 many dentists in the United States are reluctant to seal carious teeth, as they are concerned that the caries will progress underneath the sealant.101,102 Fontana et al. addressed this barrier to sealant utilization in a recent a study in which the authors sealed noncavitated lesions with a clear sealant and monitored these lesions with visual inspection, radiography, and laser uorescence.42 e use of radiography and laser uorescence added objective ways to measure caries progression, since visual inspection can be subjective. After almost 4 years of follow-up, sealantsthatwerereappliedyearlyasneededandwere98%eectivein preventing progression of lesions (Fig. 33.6). is study is part of the rapidly growing body of high-quality evidence emphasizing the power of the sealant.However, practitioners who are concerned about sealing over caries will often decide to take an invasive approach by prepping the tooth “just in case.” Some will erroneously call this a “preventive resin restoration” (PRR) when, in fact, it is most likely a ssurotomy or enameloplasty procedure. e PRR is more appropriately termed the conservative adhesive resin restoration. (See Chapter 22 for a detailed discussion of conservative adhesive restorations.) e most contemporary denition of a PRR (conservative adhesive restoration) is that one area (pit/ssure) of the occlusal surface has a lesion that is cavitated and extends to dentin while the rest of the surface remains noncavitated or caries-free. An example of this would be a permanent maxillary rst molar where the distal pit of the occlusal surface is carious but the central pit and radiating ssures remain caries-free. In this instance, the distal lesions and half of which had sound occlusal surfaces.92 e teeth were then extracted and the ssures were examined with a scanning electron microscope. Enamel defects were noted for all of the teeth with initial caries and for two of the sound surfaces. Forceful use of an explorer in demineralized ssures can, in essence, cause cavitation by creating an entrance through which cariogenic microorganisms can penetrate into the softened substructure.91 Opponents of the explorer do not endorse eliminating the explorer altogether. ey recommend that the explorer be used dierently, mainly to eliminate plaque in the ssures and to determine surface roughness of incipient lesions89: “e tip of the explorer should be moved gently across the surface of any non-cavitated area to determine the presence or absence of surface roughness as an indication of whether the underlying demineralized area reects an active lesion.”e concept of using moderate, rm pressure to nd a “catch” in the ssure is no longer the most contemporary approach to caries diagnosis and management. e use of explorers is not necessary for the detection of early lesions, since it does not improve the validity of the diagnosis of ssure caries, and visual examination of a clean, dry tooth is sucient to detect early lesions.8,88 Several new technologies have shown promise to aid in caries diagnosis and in caries monitoring over time: light-induced and infrared laser uorescence devices, the electronic caries detector, quantitative laser uorescence, and transillumination. However, to date, no technology can substitute for a thorough visual exam and clinical judgment based on experience.Sealing Over Incipient CariesA paradigm shift has occurred in the management of carious lesions. One hundred and fty years ago, complete removal of all traces of caries was the gold standard; however, advances in theeldofcariologyhavechallengedthisperspective.In2015,agroup of cariology experts from around the world convened for the International Caries Consensus Collaboration (ICCC), which reported the group’s clinical recommendations for carious tissue removal and cavity management. e experts agree that a tooth should not be restored surgically until the lesion is cavitated and into dentin. Hence early lesions—ones that are in enamel or just into dentin and are noncavitated—should be managed through biolm removal (i.e., toothbrushing) and/or remineralization or by sealing over them.93Baseline Pre-Sealant(0-months)ICDAS 4; x-ray D1Diagnodent 52(Taken with Sunicamera)Post-Sealant(12-months)ICDAS 4; x-ray D1Diagnodent 45(Taken with Digidoccamera)Post-Sealant(24-months)ICDAS 4; x-ray D1Diagnodent 59(Taken with Digidoccamera)Post-Sealant(44-months)ICDAS 4; x-ray D1Diagnodent 52(Taken with Digidoccamera)• Figure 33.6 Sealed carious permanent molars monitored over 44 months. ICDAS, International Caries Detection and Assessment System. (From Fontana M, Platt JA, Eckert GJ, et al. Monitoring of sound and carious surfaces under sealants over 44 months. J Dent Res. 2014;93:1070–1075.) CHAPTER 33 Pit and Fissure Sealants: Scientic and Clinical Rationale 469 recommended clinical management.41 As one can appreciate, surgical intervention is much further down the continuum than likely indicated by the training of many practitioners in the United States. In summary, unless the lesion is a cavitated, dentin carious lesion, it should be sealed.93Preparing the Tooth for a SealantCleaning the ToothFor a resin-based sealant to ow into the ssures of the tooth, the ssures must be free of debris. Several methods have been suggested for cleaning the ssures. Historically it has been advocated to clean the tooth with pumice slurry and a prophy cup or bristle brush; however, other cleaning methods have been shown to be eective. Debris can be cleaned using an explorer through the ssures and forcefully rinsing with air-water spray38 or with a dry bristle toothbrush.103 A recent clinical study showed improved retention with the pumice slurry and rubber cup cleaning method.104 Complete debridement of the ssures is very dicult, and as a result complete penetration of the sealant rarely occurs with conventional cleaning methods.105,106 A superior cleaning method is the utilization of an air-polishing system such as a Prophy Jet, as it removes more debris than conventional methods (Fig. 33.8).107,108 is in turn allows greater sealant penetration and an increased number of resin tags for micromechanical retention.109–111 Despite these advantages, air-polishing most likely never became the standard for pit and ssure sealant application, due to the increased equipment cost and complexity of the procedure without signicantly improved retention rates.40,112Mechanical PreparationMinimally invasive techniques have been described to improve the penetration and retention of ssure sealants. e ssurotomy pit is opened, caries is removed, and intact pit and ssures are not opened with a bur. A restorative material (composite, glass ionomer, amalgam) is placed in the distal pit cavity prep, and sealant is utilized over the remaining intact pits and ssures. Hence the “preventive” portion of the “PRR” is placing sealant over intact but susceptible pits and ssures. e PRR (conservative adhesive restoration), when utilized as discussed previously, is an excellent restoration, especially if the sealant is reapplied as needed. However, it cannot be overemphasized that mechanical preparation of a noncavitated lesion is not necessary. Once a permanent tooth has been restored, it begins the cycle of restoration. e restoration will likely be replaced several times during that person’s life, and repeated restorations may compromise the survival of the tooth itself. Fig. 33.7 is a diagram of the continuum of caries and the Primary prevention at thepatient levelCaries risk assessment at the patient levelNodiseaseICDAS 0InitiallesionICDAS 1InitiallesionICDAS 2ModeratelesionICDAS 3ModeratelesionICDAS 4ExtensivelesionICDAS 5ExtensivelesionICDAS 6Stagingof lesionseverityAdditionalinformationthat informsdiagnosisCaries lesion activity assessmentRadiographs and other diagnostic aidsCaries risk assessment at the tooth surface levelDIAGNOSISNotreatmentRemineralize Arrest Sealant MinimalsurgicalTraditionalsurgicalEndodontictreatmentExtractionSecondary prevention Tertiary prevention (care)• Figure 33.7 Caries diagnosis and management system continuum. ICDAS, International Caries Detec-tion and Assessment System. (From Zero DT, Zandona AF, Vail MM, Spolnik KJ. Dental caries and pulpal disease. Dent Clin North Am. 2011;55:29–46.)• Figure 33.8 The Cavitron Prophy Jet. (Courtesy DENTSPLY Profes-sional, York, PA.) 470 Part 4 The Transitional Years: Six to Twelve YearsIn addition, as discussed earlier, sealant can be placed over incipient, noncavitated lesions without removal of tooth structure. ere is a signicant volume of evidence of high sealant retention without the use of a bur.Eect of a Recent Professionally Applied Fluoride TreatmentDentists might note the need for sealant placement or sealant repair at a patient’s dental exam and would like to complete the procedures the same day. However, many patients receive a pro-phylaxis and uoride application prior to their dental exam. Hence the concern that uoride might inhibit or decrease sealant bond strength has been explored. Multiple studies conrm that sealant bond strengths and retention rates are not aected by a topical uoride gel or foam treatment prior to sealant application.131–133 If a patient has had a gel or foam application, the practitioner need not delay sealant application or repair. However, many oces exclusively use uoride varnish. For these practitioners, the teeth should be examined and sealed prior to the application of varnish (Box 33.1).Factors Aecting Sealant SuccessEtchantEtchants are available as separate phosphoric acid etchants, self-etching systems, liquids, and gels. Historically the clinical sealant procedure involved an etching time of 60 seconds and a rinsing time of at least 10 seconds. However, multiple studies have shown similar bond strengths for both permanent and primary teeth, withloweretchingtimesof15to30seconds.134–137 Etching time should be increased for uorotic teeth. e usual recommendation and enameloplasty techniques involve utilizing a small bur to remove any residual debris and/or dubious enamel tissue as well as to widen the ssure, leading to increased enamel surface and improved penetration of the sealant into the ssure.113 In lab studies, the enameloplasty allows deeper sealant penetration and better adapta-tion as well as increases the surface area for acid etching,114,115 but studies conict as to whether the technique decreases microleakage.43 While one recent systematic review concluded that a preparation method before ssure sealant application can increase sealant retention, the review included a number of dierent preparation methods besides a bur, including cleaning the ssure with a rubber cup, air abrasion, and the use of a carbon dioxide laser.113 When examining the use of a bur only, the literature is conicting regarding any clinical benet from mechanical preparation. Several studies have reported increased retention of sealants after mechanical preparation of the ssures,116–119 while other studies have not shown a superior retention rate or enhanced performance of the sealant.120–123 A limited number of studies have shown that air abrasion in combination with acid-etching results in improved retention of sealants124–126; however, air abrasion alone cannot be a substitute for acid etching.127–129Other disadvantages to invasive techniques are that mechanical preparation limits the delegation of sealant placement to auxiliaries, which decreases cost-eectiveness, and opening the ssures by bur preparation can predispose the teeth to caries after sealant loss.113 e European Academy of Pediatric Dentistry summarizes the evidence well in its guidelines that state: “purposeful removal of enamel or enameloplasty just to widen the base of a ssure in a sound tooth is an invasive technique, which disturbs the equilibrium of the ssure system and exposes a child unnecessarily to the use of a handpiece or air abrasion.”130 ey conclude that plaque should be removed in order to obtain sucient bonding, but that the removal of tooth structure by a bur is unnecessary and undesirable. IsolationIsolation should be achieved by any of the methods previously mentioned. The most common method of isolation is the cotton roll method, as described by Waggoner and Siegal140:The patient is in a supine position with the head extended back and the chin up because this improves visibility and moisture control.For maxillary isolation: a triangular buccal isolation shield, such as a Dri-Angle (Fig. 33.12), is placed against the buccal mucosa over the Stensen duct with the apex of the triangle directed posteriorly. A cotton roll may be placed in the maxillary vestibule to hold the tissue away from the tooth. The mouth mirror is used throughout the entire procedure and should be left in position throughout the procedure until polymerization of the sealant is achieved. Besides providing indirect vision, this will also act as a shield for the tongue.For mandibular isolation: Cotton rolls are placed on both the buccal and lingual sides of the teeth. A cotton roll holder may be utilized or the rolls may be held in place with the ngers. Waggoner and Siegal advocate utilizing a triangular isolation shield as a tongue shield by bending the apex of the triangular shield at a right angle (Fig. 33.13). This bend is placed between the lingual cotton roll and the alveolar ridge so that the larger portion of the shield rests on the tongue. This prevents the tongue from pushing saliva over the lingual cotton roll. Changing cotton rolls or adding additional cotton rolls is unnecessary. Excess moisture can be evacuated from the area with the high volume evacuation suction. Utilizing a four-handed delivery method will increase the success of achieving adequate isolation.EtchingOnce isolated, the tooth is etched, most commonly with 37% phosphoric acid. The etchant can be applied liberally and should ow onto all of the susceptible pits and ssures, including lingual grooves of maxillary molars and buccal pits of mandibular molars (Fig. 33.14). The etchant should extend up the cuspal line angles, 2 to 3 mm beyond the anticipated margin of the sealant. The etchant should remain on the surface for 15 to 20 seconds.Rinsing and DryingThe tooth should be rinsed utilizing the air-water spray and high volume suction. The goal of rinsing is to remove all of the etchant from the tooth surface. The tooth should then be thoroughly dried until the surface appears chalky or frosted (see Fig. 33.9A and B). Unlike dentin bonding, in which the collagen brils should remain moist to prevent collapsing, the enamel keeps its crystalline structure. This means that the enamel should be thoroughly dried or desiccated to maximize the penetration of the hydrophobic sealant. The tooth must remain dry and uncontaminated from this point forward.Sealant Application and PolymerizationIf a bonding agent is to be used, it should be applied with a microbrush. The bonding agent should be lightly dried and cured. The sealant should be applied to all pits and ssures, including the lingual grooves of maxillary molars and the buccal pits of mandibular molars (Fig. 33.15). The sealant may be applied with a variety of instruments: an explorer tip, a PICH instrument (a calcium The Clinical Procedure• BOX 33.1 CHAPTER 33 Pit and Fissure Sealants: Scientic and Clinical Rationale 471 Curinge polymerization process begins when photoinitiators, most commonly camphoroquinone, absorb energy from blue light with a wavelength in the region of 470 nanometers.147 is absorption facilitates the conversion of low-viscosity monomer units into a polymer matrix. A sealant must be adequately cured in order for it to obtain its purported physical properties. If the curing time is insucient, the bonding is poor, and decreases in hardness may result, leading to subsequent sealant failure.148Several types of curing lights are available (see Chapter 21). e traditional unit is the quartz tungsten halogen (QTH) curing light unit. ese units require a fan for cooling, are relatively low-cost, are easy to maintain and repair if a bulb needs replacement, anddeliverenergydensityoutputsof400to800mW/cm2. ey have largely been replaced by light-emitting diode (LED) curing lights. LED curing lights have changed dramatically in the past decade, and units continue to oer increasing intensity.149 In general, higher energy output means that curing time can be shortened (from 40 seconds for QTH to 20 seconds with a higher powered LED for 2 mm of composite).150,151 Some of the highest powered LEDs on the market oer outputs of 1000 to more than 3000 mW/cm2 of energy and usually have “turbo,” “boost,” or “plasma” modes that oer very high energy outputs in very small increments oftime,like5seconds.Not much literature has been published either conrming or challenging recommended curing times for sealants. Most manu-facturers recommend a 20-second exposure time. However, one must consider which kind of curing light is being utilized, as not all perform equally. One study has found that 20 seconds of curing for rinsing is 20 to 30 seconds. A few studies have shown that a shorter rinse time yields similar enamel bond strengths as a 20-second rinse time.138,139 Hence the exact rinse time is not as important as ensuring that the rinse is thorough enough to remove all of the etchant from the surface.140e dierent forms of etchant (i.e., gel or liquid) have been shown to perform similarly in regard to penetration, bond strength, and clinical retention.135,141,142 On the other hand, dierent types of etchants do not provide similar results. Self-etching systems yield signicantly lower bond strengths than separate etch systems and exhibit much lower retention rates in clinical trials, as reported in a recent systematic review (highest level of evidence).143 Self-etching systems have decreased bond strengths on uncut enamel.144 Utilizing a self-etching bonding system without the use of a separate etch step is not recommended.8,143Drying Agents and TimeGiven the hydrophobic nature of resins, drying agents such as alcohol or acetone have been explored as possible treatments after the etchant step, before sealant placement. However, a laboratory study showed that the use of drying agents did not decrease microleakage or increase sealant penetration.145 Furthermore, one clinical investigation showed no signicant improvements of retention rates with the use of drying agents.146 ere is no recommended drying time. Rather, a specic result should be obtained. e occlusal surface should have a chalky or frosted appearance (Fig. 33.9). If this result is not obtained after thorough drying, the tooth should be re-etched.hydroxide, or Dycal, placer), or a small brush. Many manufacturers offer their own delivery system, which may consist of a preloaded syringe with a small tip so that the sealant can be applied directly from the syringe to the tooth. The sealant should not be overlled, to ensure that the sealant material does not extend past the etched area, to limit the amount of occlusal interference created, and to ensure optimal depth of cure. If overlling occurs, the excess material may be removed with a small brush. If small bubbles form within the sealant material, these should be teased out before polymerization. Once the sealant has been satisfactorily placed, the curing light tip should be placed as closely as possible to the surface, and the sealant should be cured for the amount of time recommended by the manufacturer, which is usually 20 seconds with an light-emitting diode curing light that has an output of 800 to 1000 mW/cm2. The operator should understand which type of curing light is being used and how its energy output can affect the exposure time. As mentioned previously, very short curing times are insufcient to achieve optimal cure, especially of opaque sealants.Evaluating the SealantOnce the sealant has been cured, the operator should visually and tactilely examine the sealant before removing the isolation materials. If the operator discovers bubbles, voids, or areas of decient material, material can be directly added at this time because the oxygen inhibited layer has not been disturbed. The sealant’s retention should also be evaluated by attempting to dislodge the sealant with an explorer. If material de-bonds, the ssure should be inspected for remaining debris. The area should be re-etched, rinsed, dried, and new sealant material applied. If some of the sealant pooled over the distal marginal ridge, a ledge may have been created that should be removed. Also, if any sealant material was misplaced into the interproximal areas, it should be removed. Most likely the excess material can be removed with an explorer or scaler. The unpolymerized layer should be removed by rubbing the surface with pumice on a cotton roll or by rinsing the surface for 30 seconds to limit the patient’s exposure to bisphenol-A.Depending on the sealant material type, the occlusion may require adjustment. Filled sealants and owable composite used as sealant require adjustment, whereas unlled sealants abrade quickly and are considered to be “self-adjusting.” The occlusion can be adjusted with the use of a round composite nishing bur in the high-speed handpiece or with a stone or round bur in the slow speed handpiece.Periodic EvaluationSealants should be evaluated at every recall visit. Retention of the sealant material is critical to its success. Partial or complete loss of a sealant results in a surface that is equally at risk for caries as one that had never been sealed. One-time sealant placement does not impart any long-term protection unless the physical barrier over the ssure, the sealant, remains intact. Loss of the sealant in any groove or pit renders that pit or ssure susceptible to caries attack. Therefore sealants should be maintained and repaired or replaced as needed. If a sealant partially remains, attempts can be made to try to dislodge the remaining material with an explorer. If it remains intact, there is no need to remove the material with a handpiece. The tooth may be cleaned with pumice and a rubber cup, and the usual sealant application steps can be followed, etching both the enamel and remaining sealant and then applying additional material.The Clinical Procedure—cont’d• BOX 33.1 472 Part 4 The Transitional Years: Six to Twelve Yearscannot be completely removed by rinsing.159 e acid etch step creates microporosities in the enamel, and if saliva touches the tooth, these porosities are occluded so the sealant cannot form resin tags to micromechanically bond to the tooth. Achieving adequate isolation is a critical step to the success of the sealant and is considered a key concept in the clinical procedure (Box 33.2).160Several studies have shown that cotton roll isolation is comparable to rubber dam isolation.116,161,162 However, a recent systematic review has shown that retention is increased when rubber dam isolation is utilized (Fig. 33.10).38 In addition, vacuum systems such as the Vac-Ejector and Isolite have been shown to produce sealant retention rates comparable to those placed under cotton roll and rubber dam isolation.163–166 (See Chapter 22 for a discussion of isolation systems.) Whenever possible, especially if concurrent operative AB• Figure 33.9 (A) Etched enamel displaying frosted appearance. (B) Note the demarcation between the chalky, etched enamel (arrow) and the shiny unetched enamel of the buccal surface. Sealant placement is very technique-sensitive. If sealant material de-bonds upon immediate evaluation, one of the following three causes is the most likely culprit:1. Debris remains in the ssure. The tooth must be clean. If plaque or organic debris remains in the ssure, the resin cannot ow into the ssure to form tags and micromechanically bond to the enamel. Clean the ssures with a rubber cup and pumice, re-etch, and complete the application steps again.2. Saliva contaminated the enamel. If isolation was not meticulously maintained and saliva contacted the occlusal surface, then saliva pooled in the microporosities created by the etchant step. Even if the operator noticed the saliva contamination and decided to dry the tooth again, the viscous saliva cannot be removed by rinsing alone. Thus the resin sealant will “oat” on the saliva and cannot form resin tags. In this case, the tooth should be re-etched, dried, and resealed with no saliva contamination.3. The tooth was not completely dry after the rinsing step. If the tooth does not appear chalky after an adequate etching time, it is most likely not dry. Enamel bonding is different from dentin adhesion. In restorative dentistry, one is advised not to desiccate the dentin; however, enamel needs to be absolutely dry prior to sealant application. If water remains in the etched enamel pores, the hydrophobic resin will “oat” on top of the water and not form resin tags. Again, no micromechanical bonding will occur, and the sealant will de-bond when evaluated with an explorer.Troubleshooting Sealant Placement• BOX 33.2 with a traditional QTH light is insucient to cure resin-based sealants to a clinically adequate depth.147 Two in vitro studies have examined the depth of cure of dental sealant with LED units that oer high energy and very short curing times, and found these very short curing times to be inadequate to optimally cure dental sealant, especially opaque material.152,153 Several factors aect the level of cure, including shade of the material, the ller content, the thickness of the material, the intensity of the curing light, and the distance of the light source from the material.154 Opaque shades, though white in color, behave more like materials in the dark shade range because they are not translucent, so light does not pass through them easily to cure deeper areas of the material. Hence clear sealants can be cured to a deeper level than opaque sealants given similar curing times.147,153 More research is necessary to determine the appropriate balance between saving chair time with faster curing and still obtaining clinically sucient physical properties of resin materials. Clinicians should ensure optimal curing by using a high-intensity light source, placing the light tip as close as possible to the sealant and maximizing the curing duration.In addition to ensuring an optimal cure, a practitioner might be able to improve retention of the sealant by delaying polymerization for several seconds after sealant application, assuming scrupulous isolation can be maintained. A study by Chosack and Eidelman found that the longer sealants were allowed to remain on the etchedsurface beforepolymerization (20seconds vs.5 or10seconds), the more sealant material penetrated into microporosities, creating longer resin tags, which are critical for micromechanical retention.155IsolationResin-based sealants are moisture-sensitive. Saliva contamination signicantly lowers bond strengths because it prevents the formation of resin tags that alter mechanical retention and thus results in decreased retention.156–158 At times, practitioners who are placing sealants will notice that a small amount of saliva seeps onto the tooth from the tongue or the cotton roll, and the practitioner erroneously believes that if the tooth is rinsed and dried well, the sealant retention will not be aected. However, even minimal exposure to saliva results in the formation of a surface coating that CHAPTER 33 Pit and Fissure Sealants: Scientic and Clinical Rationale 473 wet dentin. Utilizing a layer of bonding agent between the enamel and hydrophobic resin sealant has been studied to determine if this additional step could enhance retention rates. Numerous laboratory studies have found decreased microleakage and enhanced penetration of sealant material into the ssures with the adjunct of a bonding agent.170–174 A recent systematic review and meta-analysis (highest level of evidence) examined ve studies that met inclusion criteria. Results of the meta-analysis indicated that adhesive systems beneath ssure sealants had a signicant positive benet on retention and thus caries prevention.175 e authors note that the positive eect was seen in studies that used fth-generation bonding agents (those that require a separate etch and rinse step but have the “prime” and “bond” together as one step). It seems that the smaller molecular size of the adhesive components, compared with the sealant components, penetrate better into enamel porosities, and this improves bond strength. Not only do permanent teeth benet from the adjunct of a bonding agent, but studies are also favorable for primary teeth; they also show similar laboratory results to that of permanent teeth with increased bond strengths and decreased microleakage when a bonding agent is utilized.176,177 e use of a bonding agent should only be utilized with hydrophobic resin-based sealant materials. Glass ionomers chemically bond to the enamel, so utilizing a bonding agent under this material is not logical.Another advantage of utilizing a bonding agent is noted for hypomineralized permanent molars, which often present a chal-lenge for the dentist regarding adhesive dentistry. ese teeth often have enamel defects and are at higher risk for eventually needing restorative treatment compared with “normal” teeth.178 Hence these teeth are excellent candidates for preventive eorts. However, research has shown that hypomineralized teeth need to be retreated with sealant application after a much shorter time period than teeth in the control group.179 e addition of a bonding agent with sealant application in hypomineralized teeth can increase ssure sealant retention compared with acid etching alone.180Even though recent systematic review shows a positive eect for the use of a bonding agent, there are two main disadvantages to this technique. Utilizing a bonding agent increases the cost of the procedure and increases chair time.40 Several studies have found this step to be unnecessary,47,181–183 and they highlight the importance of proper sealant placement technique: fastidious isolation and proper placement negate the need for this additional step. However, a bonding agent should be used when “in the opinion of the dental professional, the bonding agent would enhance sealant retention in the clinical situation.”8Auxiliary ApplicationWell-trained dental auxiliaries are procient at the application of pit and ssure sealants. As early as 1976, Stiles et al. reported “no dierence in the retention of the sealant when applied by a dentist or a trained dental auxiliary.”184 Since then, several studies have examined sealant placement by auxiliaries and found high retention rates.185–188 In addition, delegating sealant application is cost-eective and results in increased sealant usage.185 In studies addressing sealant longevity by operator, researchers found that proper education of personnel and following up on each individual’s aptitude in sealant placement are essential, as “individual operator rather than provider type is highly sensitive to sealant success or failure.”189,190 Hence both dental assistants and dental hygienists are as procient in sealant application as the dentist, and the treatment is provided, rubber dam isolation should be used. However, given the discomfort that can be associated with rubber dam placement on nonanesthetized tissues, rubber dam isolation is not imperative as long as the operator can maintain a dry eld with alternative techniques.Timing of Sealant Placemente timing of sealant placement has been known to correlate with the overall retention of the sealant, as studies have shown that partially erupted teeth require repair or replacement more often than fully erupted teeth.167 Dennison et al. concluded that when the operculum of the gingiva extended over the distal marginal ridgeofthetooth,morethan50%oftheteethhadtoberesealeddue to sealant loss within 36 months; when the operculum was at the level of the marginal ridge, retreatment fell to 26%.168 Except for high-risk children, sealant placement should be delayed until the gingival tissues are at or below the marginal ridge.140 For partially erupted teeth, which are at high risk for experiencing caries, the best practice is to place a sealant and repair or replace it as necessary. Utilizing a bonding agent for these teeth under the sealant may be benecial.169 Alternatively, the sealant in this scenario may be a glass ionomer sealant if the practitioner has diculty achieving adequate isolation.8Not only should tooth eruption be considered when deciding when to place a sealant, but a child’s level of cooperation must also be considered. e child must be able to tolerate the isolation method and the length of the procedure to place a successful sealant. If the child is unable or unwilling to cooperate for the procedure, placing sealants should be delayed until the level of cooperation is adequate, or if the child has high caries risk, an ART sealant with a glass ionomer could be used as a transitional sealant.Use of Intermediate Bonding AgentResin-based dental sealants are hydrophobic. Due to this property, they cannot stand even slight moisture contamination. Dentinal bonding agents have hydrophilic properties so that they can inltrate • Figure 33.10 Rubber dam isolation can be single tooth or quadrant depending on the needs of the patient and will assist the practitioner in keeping saliva from contaminating any of the ssures once they have been etched. 474 Part 4 The Transitional Years: Six to Twelve Yearsouter third of dentin). ese treatments are signicantly more eective at arresting lesions compared with other preventive methods like uoride varnish or recommending ossing.195Sealing RestorationsGiven the caries preventive eect of sealant application, researchers have examined other uses for sealants, such as increasing restoration longevity by sealing over the restoration, repairing the margins of restorations, and preventing enamel demineralization (“white spot lesions”) around orthodontic brackets (Fig. 33.11). Several studies have shown that restoration longevity can be increased by sealant application along the margins of both composite and amalgam restorations.94,196,197In 1998,Mertz-Fairhurst etal. comparedconventional amalgams to both sealed amalgam restorations and to sealed composite restorations placed over frank caries without caries removal (only a 1-mm bevel was placed around the lesion in intact enamel).94 In the 10-year follow-up, they found that the conventional amalgam restorations had the highest occurrence of open margins and the highest rate of recurrent caries, while the sealed amalgams had the best outcomes with only one clinical failure noted in the entire group. Considering that sealing over restorations signicantly reduces microleakage, one would expect sealed restorations to show decreased incidences of recurrent caries.198 literature supports the delegation of sealant application to qualied personnel.Four-Handed DeliveryNo clinical trials have addressed the two-handed versus four-handed delivery on the retention of pit and ssure sealants. However, expert opinion supports the use of a trained dental assistant or auxiliary during sealant placement.191 Having an assistant during sealant appli-cation may improve the quality and eciency of sealant placement, improve isolation, shorten placement time, reduce operator fatigue, and enhance patient care.191 Grin et al. found a positive association for four-handed delivery and increased retention rates; however, this is considered indirect evidence and is weaker than randomized controlled trials.191 Nevertheless, given this positive association, when possible, sealants should be applied with the assistance of trained personnel.8School-Based Sealant ProgramsSchool-based sealant programs have been developed to increase sealant usage to reduce caries and to provide prevention services to children less likely to receive dental care, such as those children from minority or low-income backgrounds. In 2001, the Centers for Disease Control and Prevention (CDC) created a Task Force to review the scientic evidence of the ecacy of school-based programs. Based on ndings that the median caries reduction was 60% for children aged 6 through 17 years, the Task Force endorsed school-based sealant programs in 2002.192 School-based sealant programs can (1) help serve low-income children who are at high risk of developing caries and are less likely than their higher-income counterparts to have a dental visit, (2) connect participating students with sources of dental care in the community, and (3) enroll eligible children in public insurance programs.193 However, despite the CDC’sTaskForceendorsement,in2013only15stateshadprogramsin more than half of schools where most students were low income.194 A recent economic analysis reported that providing sealantsinschoolprogramsto1000childrenwouldprevent485llings,toothachesforayearin133children,and1.59disability-adjusted life-years. School-based sealant programs save society money and remain cost-eective.194 ey are “an important and eective public health approach that complements clinical care systems in promoting the oral health of children and adolescents.”193Other Uses for SealantInterproximal Dental SealantTwo techniques can be utilized for sealing interproximal lesions, which have been termed “microinvasive” interventions. e rst is to use ssure sealant material with the etch and rinse technique. If the lesion is visible, such as the mesial of a permanent rst molar when the second primary molar exfoliates, the sealant can be directly applied. Otherwise, orthodontic separators are placed, and the material is applied at a later date when the teeth are separated and the lesion is visible. e second technique is to utilize a resin inltration system, such as ICON (DMG America, Englewood, NJ). (See Chapter 40 for a more detailed discussion of the tech-nique.) A recent Cochrane systematic review concluded that microinvasive treatments (i.e., interproximal sealants) arrest noncavitated enamel and early dentinal lesions (limited to the • Figure 33.11 Generalized demineralization after orthodontic treatment. (From Cobourne MT, DiBiase AT. Handbook of Orthodontics. Edinburgh: Mosby; 2010.)• Figure 33.12 Dri-Angle isolation shield. (Courtesy Dental Health Prod-ucts, Inc., Niagara Falls, NY.) CHAPTER 33 Pit and Fissure Sealants: Scientic and Clinical Rationale 475 brackets, commonly called “white spot lesion” (WSL) (see Fig. 33.11). e literature regarding the ecacy of dental sealants in preventing these lesions is conicting. Several laboratory studies have found that utilizing a lled sealant around the orthodontic bracket is more eective at decreasing demineralization compared with unlled products and uoride.203–205 In addition, others have reported reduced severity and signicant reductions in demineraliza-tion around brackets when sealant is used.206–208 In contrast, other authors report no dierence between the decalcication rates of treatment groups versus controls and conclude that sealants alone do not suce as a stand-alone method to prevent WSL,209 and the additional time and expense of using sealant to prevent decalcication is not justied.209–212 Further research is required to determine the eectiveness of sealant application to prevent enamel decalcication.Sealant SafetyIn 1996 Olea and colleagues released an article that started a controversy about the safety of dental sealants, as they conrmed the estrogenicity of a sealant containing bisphenol-A diglcidylether methacrylate (bis-GMA) and found free bisphenol-A (BPA) in saliva samples of subjects after sealant placement.213 BPA is a synthetic chemical resin used in the production of plastic products. Human exposure is to BPA is widespread: in one study, CDC scientistsfoundBPAintheurineofnearlyallofthe2517peopletested.214 Exposure to BPA is of concern because some animal studies report deleterious eects in fetuses and newborns exposed to BPA.215 Given that the National Toxicology Program has concluded that there is “some concern” for adverse eects on the brain, behavior, and prostate gland in fetuses, infants, and children at current human exposure levels to BPA, the question arises: Are there any adverse events when using dental sealants that contain resin?e evidence suggests that exposure to BPA from dental sealants is transient216 and that patients are not at risk.217 Moreover, clinicians can limit the amount of patient exposure to BPA (Table 33.1).218 Resin-based sealants improve children’s oral health, and since BPA exposure from dental materials appears transient and can potentially • Figure 33.13 Isolation of a mandibular molar utilizing a cotton triangle to shield the tongue. Note that when sealant is applied with four-handed delivery, the operator has extra help in maintaining adequate isolation (in this case, the operator is able to retract the cheek while the assistant retracts the tongue with mirrors). • Figure 33.14 Etchant application to a mandibular molar. Note how the etchant extends onto the buccal and lingual grooves. • Figure 33.15 Sealed mandibular molar. Note how the sealant extends into all susceptible ssures, including the buccal groove (arrow). In addition to preventing recurrent caries, sealants can increase the longevity of restorations through repair of marginal defects.199 Several studies have shown success in repairing marginal defects with sealant.196,199,200 Serious consideration should be given to repairing marginal defects over replacement of the restoration, because repair is the most conservative treatment option, as it does not result in any further loss of tooth structure and it also lowers the cost of replacement.199 Practitioners should seal restorations immediately after they are placed201 and repair margins with a sealant whenever possible.202 Sealed restorations are superior to unsealed restorations in conserving sound tooth structure, protecting margins, preventing recurrent caries, and prolonging the clinical survival of the restorations.Preventing White Spot LesionsA complication of poor oral hygiene during orthodontic treatment is the development of demineralized enamel around the orthodontic 476 Part 4 The Transitional Years: Six to Twelve Yearsthe oral health and quality of life of our children, adolescents, and adults.References1. Dye BA, Tan S, Smith V, et al. Trends in oral health status: United States, 1988-1994 and 1999-2004. Vital Health Stat 11. 2007;248:1–92.2. Benjamin RM. Oral health: the silent epidemic. Public Health Rep. 2010;125(2):158–159.3. Dye BA, ornton-Evans G, Li X, et al. Dental caries and sealant prevalence in children and adolescents in the United States, 2011-2012. NCHS Data Brief.2015;191:1–8.4. Dye B, ornton-Evans G, Li X, et al. Dental caries and tooth loss in adults in the United States, 2011-2012. NCHS Data Brief. 2015;197:197.5. NationalInstitutesofHealth.NIHConsensusStatement.Diagnosisand Management of Dental Caries roughout Life. NIH Consens Statement. 2001;18(1):1–23. http://www.dentalwatch.org/basic/nih.pdf. Accessed August 17, 2017.5a. FederalPovertyLevel:Yearlyincomeof$24,600forafamilyof4;US Department of Health and Human Services. Annual Update of the HHS Poverty Guidelines. Fed Regist.2017;82(19):8831–8832.https://www.federalregister.gov/documents/2017/01/31/2017-02076/annual-update-of-the-hhs-poverty-guidelines. Accessed August 17, 2017.6. U.S. General Accounting Oce. Report to Congressional Requesters. Oral Health: Dental Disease Is a Chronic Problem Among Low-Income Populations. Washington, DC: 2000. http://www.gao.gov/new.items/he00072.pdf. Accessed August 17, 2017.7. Tomar SL, Reeves AF. Changes in the oral health of US children and adolescents and dental public health infrastructure since the release of the Healthy People 2010 Objectives. Acad Pediatr. 2009;9(6):388–395.8. BeauchampJ,CaueldPW,CrallJJ,etal.Evidence-basedclinicalrecommendations for the use of pit-and-ssure sealants: a report of the American Dental Association Council on Scientic Aairs. J Am Dent Assoc.2008;139(3):257–268.9. Ekstrand KR, Christiansen J, Christiansen ME. Time and duration of eruption of rst and second permanent molars: a longitudinal investigation. Community Dent Oral Epidemiol. 2003;31(5): 344–350.10. Antonson SA, Wanuck J, Antonson DE. Surface protection for newly erupting first molars. Compend Contin Educ Dent. 2006;27(1):46–52.11. Wright JT, Crall JJ, Fontana M, et al. Evidence-based clinical practice guideline for the use of pit-and-ssure sealants: a report of the American Dental Association and the American Academy of Pediatric Dentistry. J Am Dent Assoc.2016;147(8):672–682e12.12. Hicks JFC. Pit and ssure sealants and conservative adhesive restora-tions: scientic and clinical rationale. In: Pinkham JR, et al, eds. Pediatric Dentistry: Infancy rough Adolesence. 4th ed. St. Louis: Elsevier;2005.13. Wright JT, Tampi MP, Graham L, et al. Sealants for preventing and arresting pit-and-ssure occlusal caries in primary and permanent molars: a systematic review of randomized controlled trials—a report of the American Dental Association and the American Academy of Pediatric Dentistry. J Am Dent Assoc.2016;147(8):631–645e18.14. Bhuridej P, Damiano PC, Kuthy RA, et al. Natural history of treatment outcomes of permanent rst molars: a study of sealant eectiveness. J Am Dent Assoc.2005;136(9):1265–1272.15. Ripa LW. Sealantsrevisted:an updateoftheeectivenessofpit-and-ssure sealants. Caries Res.1993;27(suppl1):77–82.16. Gift HC, Frew RA. Sealants: changing patterns. J Am Dent Assoc. 1986;112(3):391–392.17. Call RL, Mann J, Hicks J. Attitudes of general practitioners towards ssure sealant use. Clin Prev Dent.1988;10(2):9–13.be controlled, the concern about the estrogenicity of sealants should not deter their usage.11Future AdvancesAs noted earlier, since dental sealants must be applied in a moisture-free environment or they will fail, so much attention is focused on developing moisture-tolerant sealants. At least three resin dental sealants with hydrophilic chemistry have been developed: Embrace WetBond (Pulpdent, Watertown, MA), UltraSeal XT hydro (Ultradent, South Jordan, UT), and Smartseal and Loc (Detax Gmbh & Co, Ettlingen, Germany). In laboratory studies, hydro-philic sealants have shown similar physical properties to other commercially available sealants and more intimate marginal adaptation to the ssure than a traditional resin sealant.219–221 However, the clinical data for these products are limited, are primar-ily reported for Embrace WetBond, and are conicting. In clinical studies, at 1-year follow-up, Embrace compared with conventional sealants has shown better retention rates,222 poorer retention rates,223 and no dierence in retention.224 More research is needed to determine caries preventive eects of these new products. Boksman warns that the dental professional must be cautious about claims of new techniques and materials, as only one in ve dental products lives up to manufacturers’ claims.225 Some practitioners have switched to newer products and been disappointed when, owing to their poor clinical performance, they were removed from the market. Dental professionals should select dental products based on the best available science.Summarye abundance of published data leaves little room for skepticism regarding sealant success, yet some practitioners report that sealants “fall o” or that previously sealed teeth still require treatment. Acknowledging these concerns, Liebenberg emphasizes the importance of diligently following the correct clinical technique, choosing the appropriate cases, and maintaining the integrity of the sealant with reapplication as necessary in order to assist the practitioner in achieving sealant success.226 e technique is demanding and unforgiving, yet when applied per evidence-based recommendations, dental sealants can dramatically improve Recommendation RationaleSelect a product that is BPA-free or one that contains bis-GMA instead of BPA dimethacrylate (bis-DMA)Saliva can hydrolyze bis-DMA into free BPAUtilize rubber dam isolation Ideal isolation will limit exposureAfter light curing, rub the surface with pumice on a cotton roll or rinse the sealant for 30 sThe most signicant exposure to BPA occurs immediately after sealant placement because residual monomer remains in the unpolymerized, oxygen inhibited layerbis-DMA, Bisphenol-A diglycidylether methacrylate; bis-GMA, bisphenol-A glycidyldimethacrylate; BPA, bisphenol-A.Recommendations to Limit Patient Exposure to Bisphenol-A From Resin-Based Dental SealantTABLE 33.1 CHAPTER 33 Pit and Fissure Sealants: Scientic and Clinical Rationale 477 44. Duangthip D, Lussi A. Variables contributing to the quality of ssure sealants used by general dental practitioners. Oper Dent. 2003;28(6):756–764.45. IrinodaY,MatsumuraY,KitoH,etal.Eectofsealantviscosityon the penetration of resin into etched human enamel. Oper Dent. 2000;25(4):274–282.46. Montanari M, Pitzolu G, Felline C, et al. Marginal seal evaluation of dierent resin sealants used in pits and ssures. An in vitro study. Eur J Paediatr Dent.2008;9(3):125–131.47. Boksman L, McConnell RJ, Carson B, et al. A 2-year clinical evaluation of two pit and ssure sealants placed with and without the use of a bonding agent. Quintessence Int.1993;24(2):131–133.48. Barrie AM, Stephen KW, Kay EJ. Fissure sealant retention: acomparison of three sealant types under eld conditions. Community Dent Health.1990;7(3):273–277.49. Tilliss TS, Stach DJ, Hatch RA, et al. Occlusal discrepancies after sealant therapy. J Prosthet Dent.1992;68(2):223–228.50. Simonsen RJ, NealRC.Areviewof the clinical application andperformance of pit and ssure sealants. Aust Dent J.2011;56(suppl1):45–58.51. Kakaboura A, Matthaiou L, Papagiannoulis L. In vitro study ofpenetration of owable resin composite and compomer into occlusal ssures. Eur J Paediatr Dent.2002;3(4):205–209.52. GilletD,NancyJ,DupuisV,etal.Microleakageandpenetrationdepth of three types of materials in ssure sealant: self-etching primer vs etching: an in vitro study. J Clin Pediatr Dent. 2002;26(2):175–178.53. Dukic W, Glavina D. Clinical evaluation of three ssure seal-ants: 24 month follow-up. Eur Arch Paediatr Dent. 2007;8(3): 163–166.54. CoronaSA,BorsattoMC,GarciaL,etal.Randomized,controlledtrial comparing the retention of a owable restorative system with a conventional resin sealant: one-year follow up. Int J Paediatr Dent. 2005;15(1):44–50.55. Kuşgöz A, Tüzüner T, Ulker M, et al. Conversion degree, microhard-ness, microleakage and uoride release of dierent ssure sealants. J Mech Behav Biomed Mater.2010;3:594–599.56. RajtboriraksD,NakornchaiS,BunditsingP,etal.Plaqueandsalivauoride levels after placement of uoride releasing pit and ssure sealants. Pediatr Dent.2004;26(1):63–66.57. Jensen OE, Billings RJ, Featherstone JD. Clinical evaluation ofFluroshield pit and ssure sealant. Clin Prev Dent. 1990;12(4): 24–27.58. CarlssonA,PeterssonM,TwetmanS.2-yearclinicalperformanceof a uoride-containing ssure sealant in young schoolchildren at caries risk. Am J Dent.1997;10(3):115–119.59. CagettiMG,CartaG,CoccoF,etal.Eectofuoridatedsealantson adjacent tooth surfaces: a 30-mo randomized clinical trial. J Dent Res.2014;93(7suppl):59S–65S.60. Elkhadem A, Wanees S. Fluoride releasing sealants may possess minimal cariostatic eect on adjacent surfaces. Evid Based Dent. 2015;16(1):12.61. Boksman L, Carson B. Two-year retention and caries rates of UltraSeal XT and FluoroShield light-cured pit and ssure sealants. Gen Dent.1998;46(2):184–187.62. Ahovuo-Saloranta A, Hiiri A, Nordblad A, et al. Pit and ssure sealants for preventing dental decay in the permanent teeth of children and adolescents. Cochrane Database Syst Rev. 2008;(4):CD001830.63. MickenautschS,YengopalV.Caries-preventiveeectofglassionomerand resin-based ssure sealants on permanent teeth: an update of systematic review evidence. BMC Res Notes. 2011;4(1):22.64. YengopalV,MickenautschS,BezerraAC,etal.Caries-preventiveeect of glass ionomer and resin-based ssure sealants on permanent teeth: a meta analysis. J Oral Sci.2009;51(3):373–382.65. Beiruti N, Frencken JE, van’t Hof MA, etal. Caries-preventiveeect of a one-time application of composite resin and glass ionomer sealantsafter5years.Caries Res.2006;40(1):52–59.18. Hicks MJ, Flaitz CM, Call RL. Comparison of pit and ssuresealant utilization by pediatric and general dentists in Colorado. J Pedod.1990;14(2):97–102.19. Seale NS, Casamassimo PS. Access to dental care for children in the United States: a survey of general practitioners. J Am Dent Assoc. 2003;134(12):1630–1640.20. Faine RC, Dennen T. A survey of private dental practitioners’ utiliza-tion of dental sealants in Washington state. ASDC J Dent Child. 1986;53(5):337–342.21. Siegal MD, Garcia AI, Kandray DP, et al. e use of dental sealants by Ohio dentists. J Public Health Dent.1996;56(1):12–21.22. Dye BA, Li X, Beltran-Aguilar ED. Selected oral health indicators intheUnitedStates,2005-2008.NCHS Data Brief.2012;96:1–8.23. Horowitz AM, Frazier PJ. Issues in the widespread adoption of pit-and-ssure sealants. J Public Health Dent.1982;42(4):312–323.24. Primosch RE, Barr ES. Sealant use and placement techniques among pediatric dentists. J Am Dent Assoc.2001;132(10):1442–1451,quiz61.25. GlasrudPH.Insuringpreventivedentalcare:aresealantsincluded?Am J Public Health.1985;75(3):285–286.26. Glasrud PH, Frazier PJ, Horowitz AM. Insurance reimbursement for sealants in 1986: report of a survey. ASDC J Dent Child. 1987;54(2):81–88.27. Palmer C How many will have sealants in 2000? ADA News; 1992.28. ChiDL,vanderGoesDN,NeyJP.Cost-eectivenessofpit-and-ssure sealants on primary molars in Medicaid-enrolled children. Am J Public Health.2014;104(3):555–561.29. Quinonez RB, Downs SM, Shugars D, et al. Assessing cost-eectiveness of sealant placement in children. J Public Health Dent. 2005;65(2):82–89.30. Goldman AS, Chen X, Fan M, et al. Cost-eectiveness, in a random-ized trial, of glass-ionomer-based and resin sealant materials after 4 yr. Eur J Oral Sci.2016;124(5):472–479.31. Dennison JB, Straon LH, Smith RC. Eectiveness of sealant treatment over ve years in an insured population. J Am Dent Assoc. 2000;131(5):597–605.32. Forss H, Halme E. Retention of a glass ionomer cement and a resin-based ssure sealant and eect on carious outcome after 7 years. Community Dent Oral Epidemiol.1998;26(1):21–25.33. Forss H, Saarni UM, Seppa L. Comparison of glass-ionomer and resin-based ssure sealants: a 2-year clinical trial. Community Dent Oral Epidemiol.1994;22(1):21–24.34. Boksman L, Gratton DR, McCutcheon E, et al. Clinical evaluation of a glass ionomer cement as a ssure sealant. Quintessence Int. 1987;18(10):707–709.35. RaadalM,UtkilenAB,NilsenOL.Fissuresealingwithalight-curedresin-reinforced glass-ionomer cement (Vitrebond) compared with a resin sealant. Int J Paediatr Dent.1996;6(4):235–239.36. Shapira J, Fuks A, Chosack A, et al. Comparative clinical study of autopolymerized and light-polymerized ssure sealants: ve-year results. Pediatr Dent.1990;12(3):168–169.37. Houpt M, Fuks A, Shapira J, et al. Autopolymerized versus light-polymerized ssure sealant. J Am Dent Assoc.1987;115(1):55–56.38. Muller-BollaM, Lupi-Pegurier L,TardieuC, etal. Retention ofresin-based pit and ssure sealants: a systematic review. Community Dent Oral Epidemiol.2006;34(5):321–336.39. Rock WP, Potts AJ, Marchment MD, et al. e visibility of clear and opaque ssure sealants. Br Dent J.1989;167(11):395–396.40. Simonsen RJ. Pit and ssure sealant: review of the literature. Pediatr Dent.2002;24(5):393–414.41. Zero DT, Zandona AF, Vail MM, et al. Dental caries and pulpal disease. Dent Clin North Am.2011;55(1):29–46.42. Fontana M, Platt JA, Eckert GJ, et al. Monitoring of sound and carious surfaces under sealants over 44 months. J Dent Res. 2014;93(11):1070–1075.43. Hatibovic-Kofman S, Wright GZ, Braverman I. Microleakage of sealants after conventional, bur, and air-abrasion preparation of pits and ssures. Pediatr Dent.1998;20(3):173–176. 478 Part 4 The Transitional Years: Six to Twelve Yearsand disrupt remineralization. J Am Dent Assoc. 2005;136(11): 1527,29,31.90. Ekstrand K, Qvist V, ylstrup A. Light microscope study of the eect of probing in occlusal surfaces. Caries Res.1987;21(4):368–374.91. van Dorp CS, Exterkate RA, ten Cate JM. e eect of dental probing on subsequent enamel demineralization. ASDC J Dent Child.1988;55(5):343–347.92. Kuhnisch J, Dietz W, Stosser L, et al. Eects of dental probing on occlusalsurfaces–ascanningelectronmicroscopyevaluation.Caries Res.2007;41(1):43–48.93. Schwendicke F, Frencken JE, Bjorndal L, et al. Managing carious lesions: consensus recommendations on carious tissue removal. Adv Dent Res.2016;28(2):58–67.94. Mertz-Fairhurst EJ, Curtis JW Jr, Ergle JW, et al. Ultraconservative and cariostatic sealed restorations: results at year 10. J Am Dent Assoc.1998;129(1):55–66.95. SwiftEJJr.eeectofsealantsondentalcaries:areview.J Am Dent Assoc.1988;116(6):700–704.96. Grin SO, Oong E, Kohn W, et al. e eectiveness of sealants in managing caries lesions. J Dent Res.2008;87(2):169–174.97. Handelman SL, Leverett DH, Espeland M, et al. Retention of sealants over carious and sound tooth surfaces. Community Dent Oral Epidemiol.1987;15(1):1–5.98. ChapkoM.Astudyoftheintentionaluseofpitandssuresealantsover carious lesions. J Public Health Dent.1987;47(3):139–142.99. Oong EM, Grin SO, Kohn WG, et al. e eect of dental sealants on bacteria levels in caries lesions: a review of the evidence. J Am Dent Assoc.2008;139(3):271–278,quiz357–358.100. Jensen OE, Handelman SL. Eect of an autopolymerizing sealant on viability of microora in occlusal dental caries. Scand J Dent Res.1980;88(5):382–388.101. Tellez M, Gray SL, Gray S, et al. Sealants and dental caries: dentists’ perspectives on evidence-based recommendations. J Am Dent Assoc. 2011;142(9):1033–1040.102. O’Donnell JA, Modesto A, Oakley M, et al. Sealants and dental caries: insight into dentists’ behaviors regarding implementation of clinical practice recommendations. J Am Dent Assoc. 2013;144(4): e24–e30.103. Gillcrist JA, Vaughan MP, Plumlee GN Jr, et al. Clinical sealant retention following two dierent tooth-cleaning techniques. J Public Health Dent.1998;58(3):254–256.104. Hegde RJ, Coutinho RC. Comparison of dierent methods of cleaning and preparing occlusal ssure surface before placement of pit and ssure sealants: an in vivo study. J Indian Soc Pedod Prev Dent.2016;34(2):111–114.105. Garcia-GodoyF,GwinnettAJ.AnSEMstudyofssuresurfacescon-ditioned with a scraping technique. Clin Prev Dent.1987;9(4):9–13.106. Jasmin JR, van Waes H, Vijayaraghavan TV. Scanning electron microscopy study of the tting surface of ssure sealants. Pediatr Dent.1991;13(6):370–372.107. Garcia-Godoy F, Medlock JW. An SEM study of the eects of air-polishing on ssure surfaces. Quintessence Int.1988;19(7):465–467.108. StrandGV,RaadalM.eeciencyofcleaningssureswithanair-polishing instrument. Acta Odontol Scand.1988;46(2):113–117.109. Brocklehurst PR, Joshi RI, Northeast SE. e eect of air-polishing occlusal surfaces on the penetration of ssures by a sealant. Int J Paediatr Dent.1992;2(3):157–162.110. Brockmann SL, Scott RL, Eick JD. e eect of an air-polishing device on tensile bond strength of a dental sealant. Quintessence Int. 1989;20(3):211–217.111. Scott L, Greer D. e eect of an air polishing device on sealant bond strength. J Prosthet Dent.1987;58(3):384–387.112. Scott L, Brockmann S, Houston G, et al. Retention of dental sealants following the use of airpolishing and traditional cleaning. Dent Hyg (Chic).1988;62(8):402–406.113. Bagherian A, Sarraf Shirazi A. Preparation before acid etching in ssure sealant therapy: yes or no? A systematic review and meta-analysis. J Am Dent Assoc.2016;147(12):943–951.66. Frencken JE, Wolke J. Clinical and SEM assessment of ART high-viscosityglass-ionomersealantsafter8-13yearsin4teeth.J Dent.2010;38(1):59–64.67. Smith NK, Morris KT, Wells M, et al. Rationale for caries inhibition of debonded glass ionomer sealants: an in vitro study. Pediatr Dent. 2014;36(7):464–467.68. SundfeldD,MachadoLS,FrancoLM,etal.Clinical/photographic/scanning electron microscopy analysis of pit and ssure sealants after 22 years: a case series. Oper Dent.2017;42(1):10–18.69. Zhang W, Chen X, Fan MW, et al. Do light cured ART conventional high-viscosity glass-ionomer sealants perform better than resin-composite sealants: a 4-year randomized clinical trial. Dent Mater. 2014;30(5):487–492.70. LiuBY, XiaoY,ChuCH,etal.GlassionomerARTsealantanduoride-releasingresinsealantin ssure caries prevention–resultsfrom a randomized clinical trial. BMC Oral Health.2014;14:54.71. de Amorim RG, Leal SC, Frencken JE. Survival of atraumatic restorative treatment (ART) sealants and restorations: a meta-analysis. Clin Oral Investig.2012;16(2):429–441.72. Nicholson JW. Polyacid-modied composite resins (“compomers”) and their use in clinical dentistry. Dent Mater.2007;23(5):615–622.73. Pardi V, Pereira AC, Ambrosano GM, et al. Clinical evaluation of three dierent materials used as pit and ssure sealant: 24-months results. J Clin Pediatr Dent.2005;29(2):133–137.74. Pardi V, Pereira AC, Mialhe FL, et al. Six-year clinical evaluation of polyacid-modied composite resin used as ssure sealant. J Clin Pediatr Dent.2004;28(3):257–260.75. Pereira AC, Pardi V, Mialhe FL, etal. Clinical evaluation of apolyacid-modiedresinusedasassuresealant:48-monthresults.Am J Dent.2000;13(6):294–296.76. Leskinen K, Salo S, Suni J, et al. Comparison of dental health in sealed and non-sealed rst permanent molars: 7 years follow-up in practice-based dentistry. J Dent.2008;36(1):27–32.77. Heller KE, Reed SG, Bruner FW, et al. Longitudinal evaluation of sealing molars with and without incipient dental caries in a public health program. J Public Health Dent.1995;55(3):148–153.78. GrinSO,GrinPM,GoochBF,etal.Comparingthecostsofthree sealant delivery strategies. J Dent Res.2002;81(9):641–645.79. Guideline on fluoride therapy. Pediatr Dent. 2016;38(6): 181–184.80. Bravo M, Llodra JC, Baca P, etal. Eectiveness of visible lightssure sealant (Delton) versus uoride varnish (Duraphat): 24-month clinical trial. Community Dent Oral Epidemiol.1996;24(1):42–46.81. Tewari A, Chawla HS, UtrejaA. Comparative evaluation of therole of NaF, APF & Duraphat topical uoride applications in the preventionofdentalcaries–a21/2yearsstudy.J Indian Soc Pedod Prev Dent.1991;8(1):28–35.82. RipaLW,LeskeGS,VarmaAO.Longitudinalstudyofthecariessusceptibility of occlusal and proximal surfaces of rst permanent molars. J Public Health Dent.1988;48(1):8–13.83. VehkalahtiMM,SolavaaraL,RytomaaI.Aneight-yearfollow-upof the occlusal surfaces of rst permanent molars. J Dent Res. 1991;70(7):1064–1067.84. WheltonH.Overviewoftheimpactofchangingglobalpatternsof dental caries experience on caries clinical trials. J Dent Res. 2004;83(SpecC):C29–C34.85. VrbicV.Retentionofauoride-containingsealantonprimaryandpermanent teeth 3 years after placement. Quintessence Int. 1999;30(12):825–828.86. HotumanE, RollingI, PoulsenS. Fissuresealantsina group of3-4-year-old children. Int J Paediatr Dent.1998;8(2):159–160.87. Chadwick BL,TreasureET,PlayleRA. A randomised controlledtrial to determine the eectiveness of glass ionomer sealants in pre-school children. Caries Res.2005;39(1):34–40.88. Lussi A.Validity of diagnosticand treatment decisions of ssurecaries. Caries Res.1991;25(4):296–303.89. StookeyG.Shouldadentalexplorerbeusedtoprobesuspectedcarious lesions? No–use of an explorer can lead to misdiagnosis CHAPTER 33 Pit and Fissure Sealants: Scientic and Clinical Rationale 479 137. Wang WN, Lu TC. Bond strength with various etching times on young permanent teeth. Am J Orthod Dentofacial Orthop. 1991;100(1):72–79.138. SummittJB,ChanDC,BurgessJO,etal.Eectofair/waterrinseversus water only and of ve rinse times on resin-to-etched-enamel shear bond strength. Oper Dent.1992;17(4):142–151.139. Summitt JB, Chan DC, Dutton FB, et al. Eect of rinse time on microleakage between composite and etched enamel. Oper Dent. 1993;18(1):37–40.140. Waggoner WF, Siegal M. Pit and ssure sealant application: updating the technique. J Am Dent Assoc.1996;127(3):351–361,quiz91–92.141. Rock WP, Weatherill S, Anderson RJ. Retention of three ssure sealant resins. e eects of etching agent and curing method. Results over 3 years. Br Dent J.1990;168(8):323–325.142. Brown MR, Foreman FJ, Burgess JO, et al. Penetration of gel and solution etchants in occlusal ssures. ASDC J Dent Child. 1988;55(4):265–268.143. Botton G, Morgental CS, Scherer MM, et al. Are self-etch adhesive systems eective in the retention of occlusal sealants? A systematic review and meta-analysis. Int J Paediatr Dent. 2016;26(6): 402–411.144. Rosa WL, Piva E, Silva AF. Bond strength of universal adhesives: a systematic review and meta-analysis. J Dent. 2015;43(7): 765–776.145. DuangthipD,LussiA.Eectsofssurecleaningmethods,dryingagents, and ssure morphology on microleakage and penetration ability of sealants in vitro. Pediatr Dent.2003;25(6):527–533.146. Rix AM, Sams DR, Dickinson GL, et al. Pit and ssure sealant application using a drying agent. Am J Dent.1994;7(3):131–133.147. YueC,TantbirojnD,GrotheRL,etal.edepthofcureofclearversus opaque sealants as inuenced by curing regimens. J Am Dent Assoc.2009;140(3):331–338.148. Strang R, Cummings A, Stephen KW. Laboratory studies ofvisible-light cured ssure sealants: setting times and depth of polymerization. J Oral Rehabil.1986;13(4):305–310.149. Kramer N, Lohbauer U, Garcia-Godoy F, et al. Light curing of resin-based composites in the LED era. Am J Dent. 2008;21(3): 135–142.150. SchattenbergA,LichtenbergD,StenderE,etal.Minimalexposuretime of dierent LED-curing devices. Dent Mater. 2008;24(8): 1043–1049.151. Ernst CP, Meyer GR, Muller J, etal. Depth of cure of LED vsQTH light-curing devices at a distance of 7 mm. J Adhes Dent. 2004;6(2):141–150.152. KitchensB,WellsM,TantbirojnD,etal.Depthofcureofsealantspolymerized with high-power light emitting diode curing lights. Int J Paediatr Dent.2015;25(2):79–86.153. BranchalCF,WellsMH,TantbirojnD,etal.Canincreasingthemanufacturer’s recommended shortest curing time of high-intensity light-emitting diodes adequately cure sealants? Pediatr Dent. 2015;37(4):E7–E13.154. RueggebergFA,CaughmanWF,CurtisJWJr,etal.Factorsaectingcure at depths within light-activated resin composites. Am J Dent. 1993;6(2):91–95.155. ChosackA,EidelmanE.Eectofthetimefromapplicationuntilexposure to light on the tag lengths of a visible light-polymerized sealant. Dent Mater.1988;4(5):302–306.156. Barroso JM, Torres CP, Lessa FC, etal. Shear bond strength ofpit-and-ssure sealants to saliva-contaminated and noncontaminated enamel. J Dent Child (Chic).2005;72(3):95–99.157. FeigalRJ,HittJ,SpliethC.Retainingsealantonsalivarycontaminatedenamel. J Am Dent Assoc.1993;124(3):88–97.158. Fritz UB, Finger WJ, Stean H. Salivary contamination duringbonding procedures with a one-bottle adhesive system. Quintessence Int.1998;29(9):567–572.159. SilverstoneLM,HicksMJ,FeatherstoneMJ.Oraluidcontaminationof etched enamel surfaces: an SEM study. J Am Dent Assoc. 1985;110(3):329–332.114. Garcia-Godoy F, de Araujo FB. Enhancement of ssure sealant penetration and adaptation: the enameloplasty technique. J Clin Pediatr Dent.1994;19(1):13–18.115. XalabardeA,Garcia-GodoyF,BojJR,etal.Fissuremicromorphologyand sealant adaptation after occlusal enameloplasty. J Clin Pediatr Dent.1996;20(4):299–304.116. Lygidakis NA, Oulis KI, Christodoulidis A. Evaluation of ssure sealants retention following four dierent isolation and surface preparation techniques: four years clinical trial. J Clin Pediatr Dent. 1994;19(1):23–25.117. Shapira J, Eidelman E. Six-year clinical evaluation of ssure sealants placed after mechanical preparation: a matched pair study. Pediatr Dent.1986;8(3):204–205.118. GeigerSB,GulayevS,WeissEI.Improvingssuresealantquality:mechanical preparation and lling level. J Dent.2000;28(6):407–412.119. Feldens EG, Feldens CA, de Araujo FB, et al. Invasive technique of pit and ssure sealants in primary molars: a SEM study. J Clin Pediatr Dent.1994;18(3):187–190.120. De Craene GP, Martens C, Dermaut R. e invasive pit-and-ssure sealing technique in pediatric dentistry: an SEM study of a preventive restoration. ASDC J Dent Child.1988;55(1):34–42.121. LeBellY,ForstenL.Sealingofpreventivelyenlargedssures.Acta Odontol Scand.1980;38(2):101–104.122. Francescut P, Lussi A. Performance of a conventional sealant and a owable composite on minimally invasive prepared ssures. Oper Dent.2006;31(5):543–550.123. Blackwood JA, Dilley DC, Roberts MW, et al. Evaluation of pumice, ssure enameloplasty and air abrasion on sealant microleakage. Pediatr Dent.2002;24(3):199–203.124. Ellis RW, Latta MA, Westerman GH. Eect of air abrasion and acid etching on sealant retention: an in vitro study. Pediatr Dent. 1999;21(6):316–319.125. ChanDC,SummittJB,Garcia-GodoyF,etal.Evaluationofdierentmethods for cleaning and preparing occlusal ssures. Oper Dent. 1999;24(6):331–336.126. YaziciAR,KiremitciA,CelikC,etal.Atwo-yearclinicalevaluationof pit and ssure sealants placed with and without air abrasion pretreatment in teenagers. J Am Dent Assoc.2006;137(10):1401–1405.127. Kanellis MJ, Warren JJ, Levy SM. Comparison of air abrasion versus acid etch sealant techniques: six-month retention. Pediatr Dent. 1997;19(4):258–261.128. KanellisMJ,WarrenJJ,LevySM.Acomparisonofsealantplacementtechniques and 12-month retention rates. J Public Health Dent. 2000;60(1):53–56.129. RoederLB,BerryEA3rd,YouC,etal.Bondstrengthofcompositeto air-abraded enamel and dentin. Oper Dent.1995;20(5):186–190.130. Welbury R, Raadal M, Lygidakis NA. EAPD guidelines for the use of pit and ssure sealants. Eur J Paediatr Dent.2004;5(3):179–184.131. KohSH,ChanJT,YouC.Eectsoftopicaluoridetreatmentontensile bond strength of pit and ssure sealants. Gen Dent. 1998;46(3):278–280.132. KohSH,HuoYY,PowersJM,etal.Topicaluoridetreatmenthasno clinical eect on retention of pit and ssure sealants. J Gt Houst Dent Soc.1995;67(2):16–18.133. Warren DP, Infante NB, Rice HC, et al. Eect of topical uoride on retention of pit and ssure sealants. J Dent Hyg. 2001;75(1): 21–24.134. Tandon S, Kumari R, Udupa S. e eect of etch-time on the bond strength of a sealant and on the etch-pattern in primary and per-manent enamel: an evaluation. ASDC J Dent Child.1989;56(3): 186–190.135. GubaCJ,CochranMA,SwartzML.eeectsofvariedetchingtime and etching solution viscosity on bond strength and enamel morphology. Oper Dent.1994;19(4):146–153.136. Sadowsky PL, Retief DH, Cox PR, et al. Eects of etchant concentra-tion and duration on the retention of orthodontic brackets: an in vivo study. Am J Orthod Dentofacial Orthop. 1990;98(5): 417–421. 480 Part 4 The Transitional Years: Six to Twelve Yearspenetrability of pit and ssure sealants. Quintessence Int. 2009;40(9): 763–772.183. PinarA,SepetE,ArenG,etal.Clinicalperformanceofsealantswith and without a bonding agent. Quintessence Int.2005;36(5): 355–360.184. StilesHM,WardGT,WoolridgeED,etal.Adhesivesealantclinicaltrial: comparative results of application by a dentist or dental auxiliaries. J Prev Dent.1976;3(3Pt2):8–11.185. Foreman FJ, Matis BA. Retention of sealants placed by dentaltechnicians without assistance. Pediatr Dent.1991;13(1):59–61.186. ForemanFJ,MatisBA.Sealantretentionratesofdentalhygienistsand dental technicians using diering training protocols. Pediatr Dent.1992;14(3):189–190.187. IsmailAI,KingW,ClarkDC.AnevaluationoftheSaskatchewanpit and ssure sealant program: a longitudinal followup. J Public Health Dent.1989;49(4):206–211.188. NilchianF,RoddHD,RobinsonPG.esuccessofssuresealantsplaced by dentists and dental care professionals. Community Dent Health.2011;28(1):99–103.189. HolstA,BrauneK,SullivanA.Ave-yearevaluationofssuresealantsapplied by dental assistants. Swed Dent J.1998;22(5–6):195–201.190. Folke BD, Walton JL, Feigal RJ. Occlusal sealant success over ten years in a private practice: comparing longevity of sealants placed by dentists, hygienists, and assistants. Pediatr Dent. 2004;26(5): 426–432.191. Grin SO, Jones K, Gray SK, et al. Exploring four-handed delivery and retention of resin-based sealants. J Am Dent Assoc. 2008;139(3):281–289,quiz358.192. Truman BI, Gooch BF, Sulemana I, et al. Reviews of evidence on interventions to prevent dental caries, oral and pharyngeal cancers, and sports-related craniofacial injuries. Am J Prev Med. 2002;23(1 suppl):21–54.193. Gooch BF, Grin SO, Gray SK, et al. Preventing dental caries through school-based sealant programs: updated recommendations and reviews of evidence. J Am Dent Assoc.2009;140(11):1356–1365.194. Grin S, Naavaal S, Scherrer C, et al. School-based dental sealant programs prevent cavities and are cost-eective. Health A (Millwood). 2016;35(12):2233–2240.195. DorriM,DunneSM,WalshT,etal.Micro-invasiveinterventionsfor managing proximal dental decay in primary and permanent teeth. Cochrane Database Syst Rev.2015;(11):CD010431.196. Gordan VV, Shen C, Riley J 3rd, et al. Two-year clinical evaluation of repair versus replacement of composite restorations. J Esthet Restor Dent.2006;18(3):144–153,discussion54.197. Moncada G, Fernandez E, Martin J, et al. Increasing the longevity of restorations by minimal intervention: a two-year clinical trial. Oper Dent.2008;33(3):258–264.198. dosSantosPH,PavanS,AssuncaoWG,etal.Inuenceofsurfacesealants on microleakage of composite resin restorations. J Dent Child (Chic).2008;75(1):24–28.199. Moncada G, Martin J, Fernandez E, et al. Sealing, refurbishment and repair of class I and class II defective restorations: a three-year clinical trial. J Am Dent Assoc.2009;140(4):425–432.200. Moncada GC, Martin J, Fernandez E, et al. Alternative treat-ments for resin-based composite and amalgam restorations with marginal defects: a 12-month clinical trial. Gen Dent.2006;54(5): 314–318.201. Donly KJ, Garcia-Godoy F. e use of resin-based composite in children: an update. Pediatr Dent.2015;37(2):136–143.202. Green D, Mackenzie L, Banerjee A. Minimally invasive long-termmanagementofdirectrestorations:the‘5Rs.’Dent Update. 2015;42(5):413–416,19–21,23–26.203. Hu W, Featherstone JD. Prevention of enamel demineralization: an in-vitro study using light-cured lled sealant. Am J Orthod Dentofacial Orthop.2005;128(5):592–600,quiz70.204. Buren JL, Staley RN, Wefel J, et al. Inhibition of enamel demineraliza-tion by an enamel sealant, Pro Seal: an in-vitro study. Am J Orthod Dentofacial Orthop.2008;133(4suppl):S88–S94.160. LockerD,JokovicA,KayEJ.Prevention.Part8:theuseofpitandssure sealants in preventing caries in the permanent dentition of children. Br Dent J.2003;195(7):375–378.161. Eidelman E, Fuks AB, Chosack A. e retention of ssure sealants: rubber dam or cotton rolls in a private practice. ASDC J Dent Child. 1983;50(4):259–261.162. Straon LH, Dennison JB, More FG. ree-year evaluation of sealant: eect of isolation on ecacy. J Am Dent Assoc.1985;110(5): 714–717.163. Collette J, Wilson S, Sullivan D. A study of the Isolite system during sealant placement: ecacy and patient acceptance. Pediatr Dent.2010;32(2):146–150.164. Wood AJ, Saravia ME, Farrington FH. Cotton roll isolation versus Vac-Ejector isolation. ASDC J Dent Child.1989;56(6):438–441.165. Lyman T, Viswanathan K, McWhorter A. Isolite vs cottonroll isolation in the placement of dental sealants. Pediatr Dent. 2013;35(3):E95–E99.166. Alhareky MS, Mermelstein D, Finkelman M, et al. Eciency and patient satisfaction with the Isolite system versus rubber dam for sealant placement in pediatric patients. Pediatr Dent.2014;36(5): 400–404.167. Rock WP, Bradnock G. Eect of operator variability and patient age on the retention of ssure sealant resin: 3-year results. Community Dent Oral Epidemiol.1981;9(5):207–209.168. DennisonJB,StraonLH,MoreFG. Evaluatingtooth eruptionon sealant ecacy. J Am Dent Assoc.1990;121(5):610–614.169. Feigal RJ, Musherure P, Gillespie B, et al. Improved sealant retention with bonding agents: a clinical study of two-bottle and single-bottle systems. J Dent Res.2000;79(11):1850–1856.170. KoyuturkAE,AkcaT,YucelAC,etal.Eectofthermalcyclingonmicroleakage of a ssure sealant polymerized with dierent light sources. Dent Mater J.2006;25(4):713–718.171. SymonsAL,ChuCY,MeyersIA.eeectofssuremorphologyand pretreatment of the enamel surface on penetration and adhesion of ssure sealants. J Oral Rehabil.1996;23(12):791–798.172. Borsatto MC, Corona SA, Alves AG, et al. Inuence of salivary contamination on marginal microleakage of pit and ssure sealants. Am J Dent.2004;17(5):365–367.173. Hevinga MA, Opdam NJ, Frencken JE, et al. Microleakage and sealant penetration in contaminated carious ssures. J Dent. 2007;35(12):909–914.174. AsselinME,FortinD,SitbonY,etal.Marginalmicroleakageofasealant applied to permanent enamel: evaluation of 3 application protocols. Pediatr Dent.2008;30(1):29–33.175. BagherianA,SarrafShiraziA,SadeghiR.Adhesivesystemsunderssure sealants: yes or no? A systematic review and meta-analysis. J Am Dent Assoc.2016;147(6):446–456.176. Marquezan M, da Silveira BL, Burnett LH Jr, et al. Microtensile bond strength of contemporary adhesives to primary enamel and dentin. J Clin Pediatr Dent.2008;32(2):127–132.177. Swanson TK, Feigal RJ, Tantbirojn D, et al. Eect of adhesive systems and bevel on enamel margin integrity in primary and permanent teeth. Pediatr Dent.2008;30(2):134–140.178. ChawlaN,MesserLB,SilvaM.Clinicalstudiesonmolar-incisor-hypomineralisation part 1: distribution and putative associations. Eur Arch Paediatr Dent.2008;9(4):180–190.179. Kotsanos N, Kaklamanos EG, Arapostathis K. Treatment manage-ment of rst permanent molars in children with molar-incisor hypomineralisation. Eur J Paediatr Dent.2005;6(4):179–184.180. LygidakisNA,DimouG, StamatakiE.Retentionofssureseal-ants using two dierent methods of application in teeth with hypomineralised molars (MIH): a 4 year clinical study. Eur Arch Paediatr Dent.2009;10(4):223–226.181. MascarenhasAK, NazarH,Al-MutawaaS,etal. Eectivenessofprimer and bond in sealant retention and caries prevention. Pediatr Dent.2008;30(1):25–28.182. Marks D, Owens BM, Johnson WW. Eect of adhesive agent and ssure morphology on the in vitro microleakage and CHAPTER 33 Pit and Fissure Sealants: Scientic and Clinical Rationale 481 205. SalarDV,Garcia-GodoyF,FlaitzCM, etal.Potentialinhibitionof demineralization in vitro by uoride-releasing sealants. J Am Dent Assoc.2007;138(4):502–506.206. Benham AW, Campbell PM, Buschang PH. Eectiveness of pit and ssure sealants in reducing white spot lesions during orthodontic treatment. A pilot study. Angle Orthod.2009;79(2):338–345.207. Heinig N, Hartmann A. Ecacy of a sealant: study on the ecacy of a sealant (Light Bond) in preventing decalcication during multibracket therapy. J Orofac Orthop.2008;69(3):154–167.208. O’ReillyMT,DeJesusVinasJ,HatchJP.Eectivenessofasealantcompared with no sealant in preventing enamel demineralization in patients with xed orthodontic appliances: a prospective clinical trial. Am J Orthod Dentofacial Orthop.2013;143(6):837–844.209. Hammad SM, Knosel M. Ecacy of a new sealant to prevent white spot lesions during xed orthodontic treatment: a 12-month, single-center, randomized controlled clinical trial. J Orofac Orthop. 2016;77(6):439–445.210. Leizer C, Weinstein M, Borislow AJ, et al. Ecacy of a lled-resin sealant in preventing decalcication during orthodontic treatment. Am J Orthod Dentofacial Orthop.2010;137(6):796–800.211. Wenderoth CJ, Weinstein M, Borislow AJ. Eectiveness of a uoride-releasing sealant in reducing decalcication during orth-odontic treatment. Am J Orthod Dentofacial Orthop. 1999;116(6): 629–634.212. Farrow ML, Newman SM, Oesterle LJ, et al. Filled and unlled restorative materials to reduce enamel decalcication during xed-appliance orthodontic treatment. Am J Orthod Dentofacial Orthop. 2007;132(5):578e1–578e6.213. Olea N, Pulgar R, Perez P, et al. Estrogenicity of resin-based composites and sealants used in dentistry. Environ Health Perspect. 1996;104(3):298–305.214. CalafatAM,YeX,WongLY,etal.ExposureoftheU.S.populationto bisphenol A and 4-tertiary-octylphenol: 2003-2004. Environ Health Perspect.2008;116(1):39–44.215. WolstenholmeJT,RissmanEF,ConnellyJJ.eroleofbisphenolA in shaping the brain, epigenome and behavior. Horm Behav. 2011;59(3):296–305.216. FungEY,EwoldsenNO,StGermainHAJr,etal.Pharmacokineticsof bisphenol A released from a dental sealant. J Am Dent Assoc. 2000;131(1):51–58.217. Azarpazhooh A, Main PA. Is there a risk of harm or toxicity in the placement of pit and ssure sealant materials? A systematic review. J Can Dent Assoc.2008;74(2):179–183.218. FleischAF,SheeldPE,ChinnC,etal.BisphenolAandrelatedcompounds in dental materials. Pediatrics.2010;126(4):760–768.219. Kane B, Karren J, Garcia-Godoy C, et al. Sealant adaptation and penetration into occlusal ssures. Am J Dent.2009;22(2):89–91.220. O’Donnell J. A moisture tolerant resin based pit and ssure sealant: research results. Inside Dentistry.2008;4(9):108–110.221. Bagherian A, Ahmadkhani M, Sheikhfathollahi M, et al. Microbial microleakage assessment of a new hydrophilic ssure sealant: a laboratory study. Pediatr Dent.2013;35(7):194–198.222. Khatri SG, Samuel SR, Acharya S, et al. Retention of moisture-tolerant and conventional resin-based sealant in six- to nine-year-old children. Pediatr Dent.2015;37(4):366–370.223. Schlueter N, Klimek J, Ganss C. Ecacy of a moisture-tolerant material for ssure sealing: a prospective randomised clinical trial. Clin Oral Investig.2013;17(3):711–716.224. Bhat PK, Konde S, Raj SN, et al. Moisture-tolerant resin-based sealant: a boon. Contemp Clin Dent.2013;4(3):343–348.225. BoksmanL.Haverecentadvancesinadhesivesandmaterialsdictateda change in sealant protocols? Oral Health J.2006;96(10):69–78.226. Liebenberg WH. e ssure sealant impasse. Quintessence Int. 1994;25(11):741–745. CHAPTER 33 Pit and Fissure Sealants: Scientic and Clinical Rationale 481.e1 Case Study: Dental Sealant PlacementWilliam O. Dahlke, Jr.Tommy is a 7-year, 6-month-old male who presents for his 6-month recall examination and has no other chief complaint. His medical history is unremarkable. He was a full-term delivery, was breastfed until age 1, and is a typically developing child. A review of systems is noncontributory. He has never been hospitalized and takes no medications other than a daily gummy multivitamin. Tommy lives in a city with uoridated community water and is an active patient, presenting for recalls on a regular basis. He has had bitewing radiographs in your ofce on a yearly basis. Due to his exaggerated gag reex, he has never had sealants placed on his permanent rst molars. His mother reports that she has recently begun letting Tommy brush his teeth independently and without parental supervision because she thinks he is “old enough.” She does not believe he has been ossing on a regular basis. She reports that he has multiple snacks throughout the day which generally consist of snack crackers, gummy fruit snacks, and either milk or juice.Upon clinical examination, moderate plaque accumulation, moderate mandibular incisor crowding, and an operculum overlying the distal marginal ridge of tooth #30 are noted. All permanent rst molars have deep, uncoalesced pits and ssures (Fig. E33.1). Based on the ndings, two bitewing radiographs are prescribed. On the radiographs, caries to the dentin-enamel junction on the distal surface of tooth S and multiple other incipient carious lesions on the interproximal surfaces of his primary molars are diagnosed (Fig. E33.2). A comparison to bitewings taken 1 year ago reveals the caries to be newly formed.Recommended treatment for Tommy is an interproximal restoration on tooth #S and a preventive treatment plan to address the incipient lesions and the permanent rst molars. Options for the permanent rst molars include those listed in Table E33.1 and shown in Video 33.1.Questions1. Based on Tommy’s age and dental history, which of the following best signies his caries risk? a. Minimal risk b. Low risk c. Moderate risk d. High riskAnswer: d2. Considering Tommy’s caries risk and your clinical ndings, which of the following would be the best choice for therapy specically for tooth #30? a. Monitor b. Apply uoride varnish c. Glass ionomer sealant d. Resin-based sealantAnswer: cAB• Figure E33.1 (A) Frontal clinical photo of patient in occlusion. (B) Mandibular occlusal photo. • Figure E33.2 Bitewing radiographs. Preventive Plan Active Treatment PlanActive monitoring Sealant (type)Topical uoride Glass ionomerOral hygiene instruction Resin basedDietary counseling Preventive resin restorationOptions for Unsealed First Permanent MolarsTABLE E33.1 Continued 481.e2 Part 4 The Transitional Years: Six to Twelve Years3. Which of the following isolation techniques is not considered adequate for use during sealant placement? a. Cotton roll isolation b. Rubber dam c. Dry-eld vacuum systems d. All may be considered acceptableAnswer: d4. A sealant may never be considered for a tooth in which incipient caries has been diagnosed within the pits and ssures. a. True b. FalseAnswer: b 482 34 Pulp Therapy for the Young Permanent DentitionANNA B. FUKS AND EYAL NUNICHAPTER OUTLINEThe Dentin-Pulp Complex ConceptReactions to Caries and Operative ProceduresClinical Pulpal DiagnosisPatient HistoryClinical ExaminationRadiographic ExaminationDirect Pulp EvaluationVital Pulp Therapy for Teeth Diagnosed With Normal Pulp or Reversible Pulpitis Without Pulp ExposureSelective Caries Removal to Firm or Leathery Dentin and Protective LinerSelective Caries Removal to Soft Dentin—Indirect Pulp TreatmentVital Pulp Therapy for Teeth Diagnosed With Normal Pulp or Reversible Pulpitis With Pulp ExposureDirect Pulp CappingThe Pulpotomy ProcedureApexogenesisNonvital Pulp Treatment for Immature TeethApexicationLong-Term Apexication With Calcium HydroxideShort-Term Apexication With Mineral Trioxide Aggregate (One-Visit Apexication)Revascularization and RegenerationNonvital Pulp Treatment for Young Mature TeethRoot Canal Treatment in Young Mature Permanent Teethpresent in children from 6 years of age until 3 years after the eruption of the third molars. After apical closure, these teeth are classied as mature teeth. It should be kept in mind that the apposition of secondary dentin in the pulp chamber and the root canal is a continuous process. Physiologic secondary dentinogenesis represents the deposition of dentin after completion of the crown and root formation. It continues, at a much slower rate, throughout the life of the tooth.2 It is extremely important to maintain pulp vitality whenever possible, because young permanent teeth have wide root canals, and dentin apposition can prevent fracture. Root fracture is a common nding after traumatic injury in endodontically treated teeth with wide root canals.3 e aim of all treatment planning for young permanent teeth is to preserve pulp vitality, providing conditions for continuous root development and physi-ologic dentin apposition. e pulp and the dentin are closely related and are usually looked upon as one unit, the pulp-dentin complex.4,5 All procedures performed in the dentin will have an eect on the pulp.Reactions to Caries and Operative Procedurese molecular and cellular changes that take place during primary dentinogenesis are mimicked during the dentin-pulp reactions to injury. Kuttler6 proposed the concept of tertiary dentin formation, encompassing a wide range of responses, from the secretion of a regular, tubular dentin to a very dysplastic atubular dentin. ese responses are the result of dierent cellular and molecular processes, and they express reactions ranging from mild to severe stimulus. Tertiary dentin has been classied as either reaction-ary or reparative dentin, the former being secreted by surviving postmitotic odontoblasts in response to a mild stimulus. Repara-tive dentin is secreted by a new generation of odontoblast-like cells dierentiated after the death of the original postmitotic odontoblasts.2e dentin matrix is considered to be a reservoir of growth factors and cytokines sequestered during dentinogenesis. During caries progression, these molecules may be released from the dentin degraded by bacterial acids with other components of the extracellular matrix, inducing the formation of reactionary dentin.6 Members of the transforming growth factor (TGF) superfamily, specically TGF-βs, have received considerable attention in eecting mesenchymal cells and inducing dentin regeneration.ese chemotactants are hypothesized to provide the signals involved in the recruitment, proliferation, and dierentiation of The Dentin-Pulp Complex Concepte most important, and most dicult, aspect of pulp therapy is determining the health of the pulp or its stage of inammation. Consequently, an intelligent decision regarding the best form of treatment can be made. Permanent teeth in children and adolescents have a more cellular pulp and a rich vascular supply with better healing potential than in adults,1 and their degree of root develop-ment will aect the treatment plan.Immature permanent teeth are those in which root development and apical closure have not been completed. ese teeth can be CHAPTER 34 Pulp Therapy for the Young Permanent Dentition 483 should focus on swelling, local lymphadenopathy, and extraoral sinus tract. Intraoral examination should focus on the tooth sus-pected as the origin of pain, but all the teeth on the same side should be inspected carefully, because referred pain can occur. e examination includes observation of the soft tissues for redness, swelling, or sinus tract.Tooth discoloration is also an important nding, especially in traumatized teeth. Examining tissues by palpation and percussion, determining periodontal involvement, and assessing tooth mobility should follow. Special attention should be paid to fractured restora-tions or those with marginal breakdown, as these may also be indicators of pulp involvement.13 Additional tests should include thermal and electric pulp test (EPT) of the involved tooth and of an appropriate control tooth. As in primary teeth, sensibility tests, sometimes called vitality or pulp tests, such as thermal and EPT have limited reliability in young permanent teeth, and do not reect the extent of pulp inammation.14,15 Studies concluded that until innervation is completed (after 4 to 5 years in function), the EPT is not a reliable means of determining tooth vitality.16 Cold test has been found more reliable in immature permanent teeth.14,15 Reliability of sensibility tests in traumatized teeth, especially in the period adjacent to the traumatic incident is limited, because of possible damage to the pulp innervation system.17,18e presence of extraoral or intraoral sinus tract requires the performance of a tracing radiograph in order to trace the origin of the infection.19,20 When the originating tooth is detected, root canal treatment should be performed. Sensitivity to palpation in the vestibule may be indicative of an acute apical pathologic process. Emphasis should be placed on soft tissue swelling or bony expansion in the area, which may indicate the presence of Garré osteomyelitis.21Pain to percussion does not indicate the state of the pulp inammation; rather, it is an indication of inammation in the PDL. is inammation is most often a result of pulp inamma-tion that extended into the PDL or a sequel of dental trauma.22 Periodontal probing is part of the intraoral examination; bone loss can be a consequence of reversible (treatable) or irreversible (untreatable) pulpitis.20 Diagnosis of reversible pulpitis indicates that the inammation should resolve and vital pulp therapy is a potential treatment option. Treatment options range from indirect pulp treatment (IPT), to direct pulp capping, to partial or cervical pulpotomy. It depends on the progress of the inammatory process within the pulp and the degree of root development. Clinically the dierence between reversible and irreversible pulpitis is fre-quently determined on the basis of the duration and intensity of the pain. Prolonged response to cold stimuli, spontaneous pain, or referred pain will lead to a diagnosis of irreversible or untreatable pulpitis. Although in primary teeth pulpectomy is the treatment of choice in these cases, immature permanent teeth should be carefully considered for pulpotomy, apexogenesis, or regenerative treatment, in an attempt to enable further tooth development.18Radiographic ExaminationRadiographs should follow a careful clinical examination. Performing bitewing radiographs is necessary to assess the depth of the caries, the morphology of the pulp chamber, the height of the pulp horns, the integrity and depth of restorations, and the level of bone support. Bitewing views can also demonstrate the presence of a calcied bridge in the pulp chamber, indicating the formation of tertiary dentin by a vital pulp in response to caries or pulp treatment.the cells to the site of pulp injury to initiate tissue regeneration and dentin bridge formation.Reparative dentinogenesis encompasses a complex sequence of biological events involving stem/progenitor cells recruitment and dierentiation before matrix secretion at the site of the injury. It was demonstrated in a few in vivo studies that ethylenediamine te-traacetic acid (EDTA) solubilized dentin matrix components, shows morphogenetic activity, and can induce reparative dentinogenesis.7In addition to the caries process, various factors associated with the method of cavity preparation and restoration can inuence the tertiary dentin response. e size of the cavity, the residual dentin thickness (RDT), the etching of the cavity, and the type and method of application of the restorative material have an eect on the type and quality of the tertiary dentin. Several studies have reported that the alterations in the pulp related to the previously mentioned factors are more important than those related to the restorative materials.8–11 RDT is apparently the most signicant factor determining the secretion of reactionary dentin. Maximal reactionary dentin was observed in a study where the RDT in the cavities was between 0.5 and 0.25 mm. Reduced reactionary dentin and reduced odontoblastic survival were observed in teeth with an RDT less than 0.25 mm.11 In these deep cavities, little more than 50% of the odontoblasts survived, whereas in shallow cavities, odontoblastic survival was about 85% or greater. Despite the cutting of the odontoblastic process, the cells responded by secreting reactionary dentin.Pulp exposure in young permanent teeth is mainly the conse-quence of caries or trauma. In carious exposures, the pulp and the dentin are infected, whereas in iatrogenic exposures during operative procedures, only the dentin may be infected; the pulp may sometimes not even be inamed. In traumatic pulp exposures, the dentin is not infected, and the pulp tissue may remain vital and uninfected if treated soon after the injury.Clinical Pulpal DiagnosisPatient Historye medical and dental history should always be carefully docu-mented. In order to make the most accurate diagnosis, information must be obtained from several sources, with thorough clinical and radiographic examinations. Belanger refers to the importance of assessing the type of pain described by the child, whether it is spontaneous or is precipitated by a stimulus.12 Sensitivity to pressure may indicate that the pulpal inammation has extended to the periodontal ligament (PDL). However, this sensitivity may also be the result of a much more innocuous situation such as a sealant placed in excess or a high restoration causing hyperocclusion.12 Children often complain of “toothaches” during the eruption of the rst permanent molars. In these cases the dentist should carefully ascertain whether the complaint is due to a pericoronitis or to biting on an operculum, rather than to pain resulting from a pulp condition. Food impaction can also mimic the symptoms of an irreversible pulp condition. In cases of trauma, both patient and parents should be asked about the timing and nature of the injury, and whether previous treatment or traumatic incidents have occurred.Clinical ExaminationBoth extraoral and intraoral examinations are important for the detection of the pulpally involved tooth. Extraoral examination 484 Part 4 The Transitional Years: Six to Twelve Yearsnow considered outdated—particularly the term infected, which conveys the idea that dental caries is an infectious disease that can be cured solely by removing bacteria (as opposed to managing the causative factors: fermentable carbohydrates and the bacterial dental biolm).27 Presently, managing a carious lesion includes several options, from the complete surgical excision, where no visible carious tissue is left prior to placement of the restoration, to the opposite extreme, where no caries is removed and noninvasive methods are used to prevent progression of the lesion.28,29In describing the clinical manifestation of caries, a group of cariology experts (International Caries Consensus Collaboration [ICCC]) agreed that it would be ideal to relate the visual, clinical appearance of the lesion directly to what is taking place histo-pathologically.30 However, as histologic terms are less helpful when communicating with dentists in the clinical setting, and for practical purposes, when trying to describe which carious tissue should be removed, the ICCC23 described the dierent physical properties associated with the dierent statuses of dentin, as follows:Soft dentin: is will deform when a hard instrument is pressed onto it and can be easily scooped up (e.g., with a sharp excavator) with little force being required.Leathery dentin: Although this dentin does not deform when an instrument is pressed on it, it can still be lifted without much force. ere might be little dierence between leathery and rm dentin, while leathery is a transition in the spectrum between soft and rm dentin.Firm dentin: is dentin is physically resistant to hand excavation, and some pressure needs to be exerted through an instrument to lift it.Hard dentin: A pushing force needs to be used with a hard instrument to engage the dentin. Only a sharp cutting-edge instrument or a bur will lift it. A scratchy sound or “cri dentinaire” can be heard when a straight probe is taken across the dentin. (For details, see Chapter 23.)To remove carious tissue in teeth with vital pulps and without signs of irreversible pulp inammation, several strategies are available, based on the above-mentioned level of hardness of the remaining dentin.28 e decision among these strategies will be guided by the depth of the lesion and by the dentition (primary or permanent).Nonselective removal to hard dentin (complete excavation or complete caries removal): is uses the same criteria for carious tissue removal both peripherally and pulpally, and only hard dentin is left. is is considered overtreatment and is no longer advocated (ICCC).Selective removal to rm dentin: is leaves “leathery” dentin pulpally while the cavity margins are left hard after removal. is is the treatment of choice for both dentitions in shallow or moderately cavitated dentinal lesions (radiographically extending less than the pulpal third or quarter of dentin).Selective removal to soft dentin: is is recommended in deep cavitated lesions (radiographically extending into the pulpal third or quarter of dentin). Soft carious tissue is left over the pulp to avoid exposure and further injury to the pulp, while peripheral enamel and dentin are prepared to hard dentin, to allow a tight seal and a durable restoration. Selective removal to soft dentin reduces the risk of pulp exposure signicantly when compared with nonselective removal to hard or selective removal to rm dentin.Stepwise removal: is is carious tissue removal in two stages. Soft carious tissue is left over the pulp on the rst step and the tooth is sealed with a provisional restoration that should be durable to last up to 12 months to allow changes in the dentin and pulp On each periapical radiograph, inspection of the PDL continuity should be done to diagnose inammatory and resorptive lesions. e interpretation of radiographs of young, immature permanent teeth can be dicult because of their normally large and open apex and radiolucent dental papilla. Less experienced dentists treating these teeth should avoid confusing pathologic changes with normal apical anatomy. In a young child, a vertical bitewing with a small size radiograph can be used instead of a periapical radiograph in order to see the periapical area of posterior teeth. Treatment decisions should not be made based on a single radio-graph, so an additional radiograph of the antimeres should be taken for comparison. e degree of root development of the aected tooth and the amount of dentin apposition along the canal should be compared with those of the contralateral tooth. It is important to remember that the root canals of permanent teeth are wider in the buccolingual plane than the mesiodistal. erefore it is dicult to determine the extent of apical closure in a regular radiograph showing only the mesiodistal plane. In the anterior region, radiographs of each central incisor should be obtained separately from a distal angulation to prevent overlapping of the PDL of the central incisor over the lateral incisor. Performing radiography in this manner is mandatory in teeth after traumatic injuries. Lateral external inammatory root resorption is a common nding in necrotic young teeth after trauma. External replacement root resorption can also be seen after traumatic injuries.18In recent years the use of cone beam computed tomography (CBCT) in endodontics has signicantly increased. CBCT is a technique that produces undistorted three-dimensional digital imaging of the teeth and their surrounding tissues at reduced cost and with less radiation for the patient than traditional CT scans. e American Association of Endodontics (AAE) and the American Academy of Oral and Maxillofacial Radiology (AAOMR) state that the use of CBCT is justied in cases in which the benets to the patient outweigh the potential risks of exposure to x-rays, especially in the case of children or young adults. CBCT should only be used when the question for which imaging is required cannot be answered adequately by lower dose conventional dental radiography or alternate imaging modalities.19Direct Pulp EvaluationIn some instances, during the clinical treatment, a nal diagnosis can only be reached by direct visualization of the pulp tissue. e quality (color) and the amount of bleeding from a direct exposure of the pulp tissue must be assessed; profuse or deep purple-colored bleeding or pus exudate indicates irreversible pulpitis. Based on these observations, the treatment plan may be conrmed or changed.Vital Pulp Therapy for Teeth Diagnosed With Normal Pulp or Reversible Pulpitis Without Pulp ExposureComplete removal of all carious tissue followed by “extension for prevention,” to place the margins of the restoration in areas less vulnerable to caries, was considered the gold standard 150 years ago.23 A paradigm shift in carious lesions treatment has occurred, and in 1997 Fusyama24 suggested that the supercial layer, grossly denaturated infected dentin, should be removed, while the underlying layer, partially demineralized caries aected dentin (containing intact, undenaturated collagen brils amenable to remineralization), should be preserved during caries excavation.25,26 ese terms are CHAPTER 34 Pulp Therapy for the Young Permanent Dentition 485 the distance between the rm (formerly called “aected”) dentin and the pulp, and in the deposition of peritubular (sclerotic) dentin, which results in decreased dentin permeability.Clinically, IPT is dened as the procedure in which nonmineraliz-able carious tissue is removed and a thin layer of caries is left at the deepest site of the cavity to prevent pulp exposure.37,42 It is important to remove the carious tissue completely from the dentinoenamel junction and from the lateral walls of the cavity to achieve optimal interfacial seal between the tooth and the restorative material, thus preventing microleakage. Several clinical studies have demonstrated a high percentage of success utilizing this technique.2,31,33,43 e indication for Selective Caries Removal to Soft Dentin (IPT) should be limited to teeth without signs of irreversible pulpitis. In this procedure, the deepest layer of the remaining carious dentin should be covered with a liner. e materials used for these procedures are calcium hydroxide liners and glass ionomer liners, with good results in clinical studies.32–43Until recent years, the dentist’s dilemma lay in the assessment of how much caries to leave at the pulpal or axial oor. It was generally believed that the carious tissue that could remain at the end of the cavity preparation was the quantity that, if removed, would result in overt exposure.44,45 In case of doubt, deep carious lesions may be managed by stepwise excavation performed in two visits that may result in fewer pulp exposures compared with direct complete excavation. At 1-year follow-up, there was a statistically signicant higher success rate with stepwise excavation than with one-visit treatment.34,46 At present, there is enough evidence of good clinical and radiographic success without reentering, if the restoration is maintained leakage free.31,47–49 Both approaches require knowledge of tooth anatomy, clinical experience, and a good understanding of the process of caries progression. If the tooth is too broken down to allow for a proper restoration, placement of a crown should be considered. Fig. 34.1 demonstrates the (Selective Caries Removal to Soft Dentin) IPT technique using a calcium hydroxide liner.e preferred tool for caries excavation is a large carbide round bur (no. 6 or 8), because the bur allows better control of the “partial removal caries step” than spoon excavators do.50 Use of a bur also results in a signicant reduction in viable counts of both Streptococcus mutans and lactobacilli.51Vital Pulp Therapy for Teeth Diagnosed With Normal Pulp or Reversible Pulpitis With Pulp ExposureDirect Pulp CappingGuidelines published by the AAPD (2016 to 2017)37 state that direct pulp capping may be performed when a small exposure of the pulp is encountered during cavity preparation in teeth with a normal pulp or reversible pulpitis. Direct capping may also be used after a recent clean fracture due to a traumatic injury. e aim of this treatment is to maintain pulp vitality by forming a calcied barrier to wall o the exposure, keeping in mind that in teeth aected by caries there is an inammatory response of the pulp to bacteria or bacterial products.52–55When direct pulp capping is indicated, it should be performed immediately after the exposure to prevent contamination of the pulp. Because the extent of the inammatory process in the pulp cannot be accurately assessed by clinical tests, the diagnosis of reversible (treatable) pulpitis may be sometimes incorrect. In some to take place. In reentering, after removing the restoration, as the dentin is drier and harder, caries removal is continued. ere is some evidence that in such deep lesions the second step might be omitted, as it increases the risk of pulp exposure.31–34e second step also adds additional cost, time, and discomfort to the patient; there is also enough evidence that is not considered necessary for primary teeth, and selective removal to soft dentin should be carried out.32Selective Caries Removal to Firm or Leathery Dentin and Protective Linere progress of a carious lesion into the dentin begins with acid demineralization produced by bacteria, followed by a more extensive tissue breakdown caused by bacterial enzymatic activity. e demineralized dentin, previously referred to as “aected dentin” and amenable to remineralization, should be left untouched, and the broken-down part, previously known as “infected dentin” should be removed.26,28,29 Clinically it is dicult to dierentiate between the dierent layers of carious dentin. As a practical approach, the remaining dentin should feel hard when examined with an explorer.A chemomechanical approach to caries excavation using dyes has been developed. With this method, sound and carious dentin are clinically separated, and only carious dentin can be removed, resulting in a more conservative preparation. When a bur is used, healthy tissue is frequently removed. It has also been reported that this method contributes to patient comfort, as it has been said to be painless, requiring less drilling and local anesthesia. e main drawback of this technique is the time needed to complete the procedure, because it is much more time-consuming than the use of a bur.35Another chemomechanical product has been developed in Brazil under the commercial name of Papacarie (Fórmula & Ação, São Paulo, Brazil). is product is a gel containing papain, an enzyme similar to human pepsine that acts as a debriding agent with no harm to healthy tissue. No statistical dierence was observed in a clinical study after 6 to 18 months when papain was used, compared with conventional caries removal in primary teeth.36e American Academy of Pediatric Dentistry (AAPD)37 recom-mends the placement of a protective barrier on the oor of the preparation between the restorative material and the pulp-dentin complex. A protective barrier is recommended in deep preparations, and the preferred materials are glass ionomer cements or calcium hydroxide liners. ere is sucient evidence to show that pulp reaction to dental materials is transitory, and overt inammation occurs only after bacteria or their by-products have reached the pulp.38–40 When bacteria and bacteria-produced irritants have been removed by caries excavation, and a bacteria-tight restoration has been placed, new bacteria are prevented from reaching the deeper portion of the dentin, and the inamed pulp will have a great opportunity to heal.Selective Caries Removal to Soft Dentin—Indirect Pulp Treatmente main objective of IPT is to maintain the vitality of teeth with reversible pulp injury or teeth with deep caries that might otherwise need endodontic therapy if the decay was completely removed (AAPD).37 e rationale for this treatment is based on the observa-tion that postmitotic odontoblasts can be induced to upregulate their secretory activities in response to reduced infectious challenge.41 is results in the deposition of tertiary dentin, which increases 486 Part 4 The Transitional Years: Six to Twelve YearsMineral trioxide aggregate (MTA) and calcium hydroxide are the most frequently recommended capping materials. e mecha-nism of action of the two materials in vital pulp treatment are similar, as the main soluble component of MTA is calcium hydroxide.57 Calcium hydroxide dissolves in an aqueous environment into calcium and hydroxyl ions, creating a high pH in the close environment (~12). is alkaline pH is responsible for the antibacte-rial activity of these materials.58 e initial eect of calcium hydroxide applied to exposed pulp tissue is the development of a teeth aected by deep caries, pulp inammation might have reached the stage of irreversible pulpitis without showing clinical signs.The characteristics of the pulp-capping material are very important. Ideally it should be biocompatible, nonresorbable, able to establish and maintain a good seal to prevent bacterial contamina-tion, and able to promote pulp repair and dentin bridge formation. Ideally the dentin bridge formed after direct pulp capping should be without tunnel defects that could allow the penetration of bacteria into the pulp at a later stage.56BCDEA• Figure 34.1 (A) Maxillary permanent second molar with deep caries almost reaching the pulp. (B) Clinical view of the tooth after incomplete caries removal. (C) The cavity was capped with a calcium hydroxide liner and covered with glass ionomer. (D) The tooth was lled with amalgam. (E) Postoperative radiograph; notice the layers of the different materials used and the remaining affected caries. (Courtesy Dr. A. Kupietsky.) CHAPTER 34 Pulp Therapy for the Young Permanent Dentition 487 pulp vitality, and radiographs were taken at the dentist’s discretion. e probability of failure at 24 months was 31.5% for CaOH versus 19.7% for MTA (permutation log-rank test, P = .046). is large randomized clinical trial provided conrmatory evidence for a superior performance with MTA as a direct pulp-capping agent, as compared with CaOH when evaluated in a practice-based research network for up to 2 years.69Direct Pulp Capping Techniquee tooth should be isolated with a rubber dam and disinfected with sodium hypochlorite (NaOCl). After cavity preparation with high-speed burs under constant water spray and caries removal with slow-speed burs, the cavity should be rinsed with NaOCl (every 3 to 4 minutes), which disinfects the cavity and removes the blood clot, if present, from the pulp exposure site. If the bleeding cannot be stopped within 1 to 10 minutes, it suggests that the pulp inammation has progressed deeper into the tissue, and the treatment procedure should be modied, for example, by shifting to partial pulpotomy.70–72MTA should be prepared according to the manufacturer’s instructions and placed directly over the exposed pulp tissue (1.5 to 2 mm thick). e material should then be covered with a glass ionomer liner followed by a permanent restoration.73The Pulpotomy ProcedureAlthough use of direct pulp capping and pulpotomy in cariously exposed pulps of mature teeth remains a controversial issue, these procedures are universally accepted in young immature permanent teeth. e pulpotomy procedure involves removing pulp tissue that has inammatory or degenerative changes, leaving intact the remaining appearing vital noninamed tissue, which is covered with a pulp-capping agent to promote healing at the amputation site.71–73e only dierence between pulpotomy and pulp capping is that in pulpotomy, additional tissue is removed from the exposed pulp. Traditionally, pulpotomy implied the removal of the entire coronal pulp up to the cervical area. Today the depth of tissue removal is based on clinical judgment: only tissue with profuse bleeding, judged to be inamed or infected, should be removed, because the capping material should be placed on healthy tissue. Although many materials and drugs have been used as capping supercial necrosis as a result of the high pH. is necrosis causes low-grade irritation to the tissue and stimulates the pulp to defense and repair. Contrary to calcium hydroxide, MTA causes mild inammatory and necrotic changes in the subjacent pulp. us it is less caustic than the traditional calcium hydroxide preparations.59 Calcium ions are released from the capping material, forming inorganic precipitations that have been associated with the mecha-nism controlling cytological and functional changes in the interacting pulpal cells.60e high pH and low solubility of calcium hydroxide prolongs its antibacterial eect. However, being water soluble, it might dissolve under leaky restorations and be washed out, leaving an empty space under the lling material. Hard-setting calcium hydroxide cements can induce dentin bridge formation, but they do not provide an eective long-term seal against bacteria or their by-products.61,62Recent studies suggest that the mechanisms by which calcium hydroxide or MTA stimulate the wound-healing process are related to the solubilizing eect of calcium hydroxide on the dentin matrix component. Growth factors and other bioactive molecules, sequestered within the dentin matrix during dentinogenesis (e.g., TGF-βs), may be released by the action of calcium hydroxide and mediate the changes in cell behavior observed during reparative dentinogenesis.4,63MTA presents some advantages over calcium hydroxide as the material of choice for direct pulp capping. It is a hard-setting, biocompatible material with an antibacterial eect that provides a biologically active substrate for cell attachment. ese features make this material eective in preventing microleakage, improving the treatment outcome. As previously mentioned, MTA stimulates reparative dentin formation with negligible pulpal necrosis and minimal inammatory reaction in the exposed pulp.59 Tziafas et al. demonstrated that after direct pulp capping with MTA in dogs, the underlying pulp tissue was consistently normal, and only at a later stage was some hemorrhage in the pulp core observed. e beginning of a hard tissue barrier was observed after 2 weeks, and reparative dentinogenesis was disclosed after 3 weeks, associated with a rm brodentin matrix.64 It was also demonstrated that, compared with calcium hydroxide, MTA consistently induces the formation of a dentin bridge at a greater rate with a superior structural integrity. erefore MTA appears to be more eective than calcium hydroxide for maintaining long-term pulp vitality after direct pulp capping.59However, MTA presents a major drawback by staining tooth material, for both the gray and white versions (Fig. 34.2).65–68 Hence its use in vital pulp therapy procedures (pulp capping, pulpotomy) is not recommended in teeth where there is an esthetic concern. In these teeth, alternatives to MTA (such as calcium hydroxide) should be considered. New generations of bioceramic materials with similar characteristics of MTA are available in the dental market. Direct pulp capping should always be followed by an immediate and denitive restoration.A practice-based, randomized clinical trial evaluated and compared the success of direct pulp capping in permanent teeth with MTA or CaOH (calcium hydroxide). irty-ve practices in the northwest dental practice-based research network were random-ized to perform direct pulp caps with either CaOH (16 practices) or MTA (19 practices). A total of 367 individuals received a direct pulp cap with CaOH (n = 181) or MTA (n = 195). ey were followed for up to 2 years at regular recall appointments, or as dictated by tooth symptoms. e primary outcomes were the need for extraction or root canal therapy. Teeth were also evaluated for • Figure 34.2 Right permanent central incisor 1.5 years after partial pulpotomy using white mineral trioxide aggregate. Notice the gray discol-oration of the crown. (Courtesy Dr. E. Nuni.) 488 Part 4 The Transitional Years: Six to Twelve Yearspreparation is thoroughly washed with NaOCl to disinfect and control hemorrhage. If hemorrhage persists, amputation should be performed at a more apical level.72 Once hemorrhage has been controlled and the blood clot removed, a dressing of MTA (or calcium hydroxide in an esthetic area) is gently placed over the amputation site. Care should be taken not to push the material into the pulp.77e MTA should be covered with a glass ionomer liner, and a permanent restoration should be placed (Fig. 34.3). If the pulpotomy is successful, a tertiary dentin bridge will be formed; occasionally, obliteration of the pulp may occur.Cervical PulpotomyPulpotomy in mature teeth is performed only when irreversible pulpitis is diagnosed, and it should be considered an emergency treatment. In these teeth, root canal treatment will follow at the next appointment. In immature permanent teeth, cervical pulp-otomy is performed to allow maturation of the root. is procedure is performed in teeth in which it is assumed that healthy pulp tissue, with a potential to produce a dentin bridge and complete the formation of the root, still remains in the root canal. e technique for cervical pulpotomy in immature permanent teeth is similar to that for primary teeth, and the dressing material should maintain pulp vitality and function. Care should be taken to remove the blood clot before placing the dressing material over agents after pulpotomy, MTA seems to be the treatment of choice to stimulate dentin bridge formation in young permanent teeth with exposed pulps.63 New generation bioceramic materials can also be used.69In esthetic areas, MTA is not recommended because of its discoloration eect. Calcium hydroxide may be used, as its outcomes are similar in some studies.73,74Aguilar and Linsuwanont reported that partial pulpotomy and full (cervical) pulpotomy provide a more predictable outcome than direct pulp capping in teeth with carious exposure.72Partial (Cvek) Pulpotomy Techniquee tooth should be isolated with a rubber dam and disinfected with NaOCl solution. In traumatically exposed pulps, only tissue judged to be inamed should be removed (~2 mm). Cvek75 has shown that, in exposures resulting from traumatic injuries, pulpal changes are characterized by a proliferative response, with inam-mation extending only a few millimeters into the pulp. Care should be taken to remove all the tissue coronal to the amputation site to prevent continuation of bleeding, contamination, and discol-oration of the tooth. In teeth with carious exposure, it might be necessary to remove tissue to a greater depth in order to reach noninamed pulp. Cutting of the tissue with an abrasive high-speed diamond bur with water cooling has been shown to be the least damaging to the underlying tissue.76 After pulp amputation, the BCA• Figure 34.3 Partial pulpotomy technique: (A) Mandibular rst permanent molar with a broken temporary lling and extensive caries. (B) Clinical view of the tooth showing two amputation sites covered with white mineral trioxide aggregate. (C) The same tooth after 2 months. No symptoms are present, and no patho-logic process is evident in the radiograph. It is recommended that the composite temporary lling be replaced by a more denitive restoration (crown), to prevent failure of the treatment due to microleakage. (Courtesy Dr. E. Nuni.) CHAPTER 34 Pulp Therapy for the Young Permanent Dentition 489 apexication or pulp regenerative procedure should follow. e use of MTA (bioceramics) as a dressing material should be carefully considered because of the diculty in removing the material from deep inside the root canal.Nonvital Pulp Treatment for Immature TeethApexicationApexication is a method of treatment for immature permanent teeth in which root growth and development ceased due to pulp necrosis. Its purpose is to induce root end closure with no canal wall thickening or continuous root lengthening. It can be achieved in two ways: (1) as a long-term procedure using calcium hydroxide dressing to allow the formation of a biologic hard tissue barrier, or (2) as a short-term (more recent) procedure, creating an articial apical plug of MTA or other bioceramic material. Apexication is most often performed in incisors that lost vitality because of traumatic injury, after carious exposures, and in teeth with anatomic variations such as dens invaginatus with an immature root.e apex in immature teeth may present two morphologic variations: divergent with aring apical foramen (blunderbuss apex) or parallel to convergent. is morphology is dicult to determine because of the two-dimensional image obtained by dental radio-graphs. In both forms, conventional endodontic treatment cannot be performed, because it is dicult if not impossible to achieve an apical seal that will prevent extrusion of the lling material. When apexification is carried out successfully in teeth with radiographic signs of rarefying osteitis, healing of the bone will be observed gradually. e tooth should continue to erupt, and the alveolar bone should continue to grow in conjunction with the adjacent teeth. Follow-up should be performed to ensure the absence of adverse posttreatment clinical and radiographic signs.For more than a decade, an alternative treatment to apexication has been available in the form of pulp regenerative therapy, even in cases of infected necrotic immature teeth. is will be discussed shortly.Long-Term Apexication With Calcium Hydroxideis mode of treatment requires compliance of both the patient and the parent because of its long duration. Calcium hydroxide apexication is a predictable procedure, and an apical barrier will the pulp stumps, as its presence may compromise the treatment outcome. It has been demonstrated that leaving the blood clot may result in the formation of dystrophic calcications and internal resorption. A blood clot may also interfere with dentin bridge formation and serve as a substrate for bacteria in leaky restorations.78 Cervical pulpotomy is frequently performed in teeth in which the histopathologic status of the pulp stumps is not clear. If the symptoms continue and pulpectomy is needed, the MTA may be removed using an ultrasonic instrument and an operative microscope.ere is a controversy as to the indications for performing root canal treatment after root maturation, before obliteration of the root canal space occurs that will prevent performing root canal treatment in the future. Prophylactic endodontic treatment is not recommended because of the low percentage of pulp necrosis.79,80Root canal treatment can be considered in posterior teeth, where apicectomy is dicult to perform in cases of treatment failure, especially in children.18Clinical and radiographic follow-up of these teeth is essential to ensure that pulpal or periapical pathosis is not developing. e roots should show continued normal development and maturo-genesis. It is of the utmost importance to perform a permanent restoration as soon as possible to prevent bacterial leakage and ensure the success of the treatment.81ApexogenesisApexogenesis is indicated in immature teeth when only part of the pulp tissue inside the root canal remains vital and apparently healthy. is procedure allows continued physiologic development and formation of the root apex apically to the dressing material.37 The root formed may be irregular but nevertheless provides additional support for the tooth. Apexogenesis can be regarded as a very deep pulpotomy. MTA, another type of bioceramic material, or calcium hydroxide is placed over the vital pulp stump after hemostasis control with NaOCl but before the formation of a blood clot (Fig. 34.4). e use of the operative microscope is recommended in order to execute this meticulous procedure correctly.It is dicult to determine the status of the pulp deep in the root canal or to predict the formation of a calcied barrier and continued root development. Radiographic and clinical follow-up is mandatory, and if signs and symptoms of pathology appear, AB• Figure 34.4 (A) Mandibular premolar with incomplete root development due to partial pulp necrosis. Apexogenesis with calcium hydroxide was instituted. (B) Two years later, apical closure was evident in the radiograph. Root canal treatment was completed using gutta-percha with a root canal sealant. (Cour-tesy Dr. E. Galon.) 490 Part 4 The Transitional Years: Six to Twelve Yearstissue barrier and to conrm the absence of pathology such as root resorption and apical periodontitis. If a calcied barrier is not evident and the calcium hydroxide has been washed out, it should usually be replaced. When a calcied barrier can be seen on the radiograph, the tooth is reopened and the calcium hydroxide is removed by copious irrigations. e apical area should be gently examined using a GP point and/or through the operative microscope to determine the completeness of the apical barrier. If the barrier is incomplete and the patient feels the touch of the GP point, the apexication procedure is reestablished until a complete barrier is formed. e frequency in which the calcium hydroxide dressing should be replaced is controversial. Some authors support a single application of the material and claim that it is only required to initiate the healing reaction, while others propose to replace the calcium hydroxide only when symptoms develop or if the material appears to have been washed out of the canal when viewed radiographically.89When a completed apical barrier can be traced, the canal is obturated with a permanent root canal filling material (e.g., thermoplasticized GP) and sealer.Fig. 34.5 shows an immature maxillary central incisor with a necrotic pulp and acute apical abscess treated with calcium hydroxide apexication. e bony lesion healed, and the endodontic treatment was properly completed.When a calcied barrier is formed coronal to the apex, it should not be perforated in order to ll the tooth to the apical end; the tissue forming the apical barrier should be regarded as healthy tissue, and root canal lling should be placed up to this point.As noted earlier, immature teeth with thin dentin walls, especially after calcium hydroxide apexication, are at high risk of fracture. e stage of root development seems to be a key factor.3,84 In order to reduce this risk, a short-term calcium hydroxide dressing and a permanent restoration with an intracanal placement of bonded composite resin is recommended.93Short-Term Apexication With Mineral Trioxide Aggregate (One-Visit Apexication)For more than a decade, MTA has been commonly used as an articial apical barrier in a short-term apexication. MTA reduces the time needed for completion of the root canal treatment and for restoration of the tooth. e apical barrier is achieved in one visit, and the whole treatment is completed in just a few visits.94MTA characteristics such as low solubility, excellent sealability, biocompatibility, release of calcium hydroxide, high pH, and radiopacity are responsible for its preferable clinical results and popularity as an apical plug material.95 Other bioceramic materials with similar characteristic can also be utilized, like Biodentine (Septodont, Saint-Maur-des-Fosses, France), NuSmile NeoMTA (NuSmile, Houston, TX), MTA Angelus (Angelus, Londrina, PR, Brazil), EndoSequence root repair material (Brasseler Savannah, GA), or iRoot BP Plus (Innovative Bioceramix Inc., Vancouver, Canada).69Disinfection of the root canal is done in the rst visit as in the long-term apexication procedure. At the second visit, MTA can be placed in the apical portion of the immature root and will act as an apical plug after setting. It is very dicult to remove the MTA from within the canal after it sets; if retreatment is necessary, it can be done by apical surgery. erefore complete debridement and disinfection of the root canal and of the dentin walls are mandatory. is technique has a number of advantages: (1) patient compliance is less crucial, (2) cost and clinical time are reduced, be formed in 74% to 100% of cases.82 e most common complica-tion is cervical root fracture due to the thin walls of the cervical part of the tooth, which may fracture easily.3It has been reported that calcium hydroxide signicantly increases the risk of root fracture after long-term application (more than 1 month) as a result of structural changes in the dentin. erefore, to reduce this risk in immature teeth, it is advisable to minimize the time needed for apical barrier formation.83,84Apexication is traditionally performed using a calcium hydroxide dressing that disinfects the root canal and induces apical closure. e high pH and low solubility of calcium hydroxide keeps its antimicrobial eect for a long period of time.85–87Calcium hydroxide assists in the debridement of the root canal, because it increases the dissolution of necrotic tissue when used alone or in combination with NaOCl.88e mechanism of action of calcium hydroxide in induction of an apical barrier is still controversial, although it is formed by cells originating from the adjacent connective tissue. e calcied barrier, even when appearing radiographically and clinically complete, is histologically porous and may be composed of cementum, dentin, bone, or osteodentin.89is procedure requires multiple visits and could take a year or more to achieve a complete apical barrier that would allow root canal lling using gutta-percha (GP) and sealer.90It is unclear whether the stage of root development at the beginning of the treatment or the presence of a pretreatment infection aects the time required for barrier formation.89Calcium Hydroxide Apexication TechniqueAfter isolation with rubber dam, coronal access preparation should be wide enough to include the pulp horns to prevent future contamination and discoloration. Gates-Glidden drills can be used in anterior teeth to remove the lingual eminence in the cervical portion of the root canal, facilitating cleaning of all aspects of the canal. e length of the root canal should be determined radio-graphically with a large GP point, because an electronic apex locator is not reliable in teeth with open apices. Inserting a large paper point to the point of bleeding may also assist in length determina-tion. e working length should be approximately 1 mm short of the radiographic root end. Debridement of the root canal is mainly achieved by irrigations with NaOCl solution. e irrigation should be done without pressure, verifying that the needle is loose inside the root canal and short of the working length. Minimal or no instrumentation is advised to prevent damage to the thin dentin walls. In order to facilitate disinfection and debris removal from these wide canals, passive ultrasonic irrigation with NaOCl solution is recommended.91A calcium hydroxide dressing in a creamy consistency can then be applied with a Lentulo spiral mounted in a low-speed engine, with specially designed syringes, or with les.e second visit is scheduled from 2 weeks to 1 month later. e goal in the second visit is to complete the debridement and remove the tissue remnants denatured by the calcium hydroxide dressing that could not be removed mechanically in the rst appointment. In addition, the canal should be further disinfected. After disinfection, a thick paste of calcium hydroxide is packed in the root canal to a level apical to the cemento-enamel junction (CEJ) using endodontic pluggers; this will reduce dentin weakening in this fracture-sensitive area.92 e coronal access should be restored with a ling that will provide a long-term coronal seal.e tooth should be monitored clinically and radiographically at 3-month intervals to examine the formation of an apical hard AB CD E• Figure 34.5 (A) Clinical photograph of a traumatized left central incisor with an acute apical abscess (notice the vestibular swelling). (B) Radiograph of the same tooth showing an incompletely formed root, an open apex, and periapical bone destruction. (C) Radiograph of the tooth lled with a calcium hydroxide paste to achieve apexication. (D) Radiograph showing the completeness of the apical barrier checked with a gutta-percha point. (E) The tooth after root canal lling with gutta-percha and sealer. (Courtesy Dr. Z. Elazary.) 492 Part 4 The Transitional Years: Six to Twelve YearsProper placement of the material is veried by a radiograph (see Fig. 34.6A). A wet cotton pellet or paper point is placed over the MTA, providing moisture for its setting, and the tooth is sealed with a temporary lling.After a few days the tooth is reentered and the hardness of the MTA is examined with an endodontic instrument. In cases where the MTA is not set, its placement should be repeated the same way described. After setting, the root canal lling can be completed using thermoplasticized GP and sealer. e tooth is then perma-nently restored with a bonded composite resin extending into the canal space in an attempt to strengthen the root.93 In short roots, the composite resin can be placed in direct contact with the MTA plug (see Fig. 34.6).18Using new generation bioceramic materials (e.g., Biodentine Allington Maidstone, Kent, UK) can shorten the treatment period even further. e short setting time of this material (~10 minutes) will allow the placement of a permanent root lling and tooth restoration at the same visit of the apical plug placement.18Revascularization and Regenerationis approach, introduced more than a decade ago, for treatment of immature necrotic and infected permanent teeth is based on the observation of spontaneous revascularization that occasionally (3) the dentin will not lose its physical properties, and (4) it allows for earlier restoration with bonded composite resin within the root canal, thus minimizing the likelihood of root fracture.Mineral Trioxide Aggregate Apexication TechniqueDisinfection of the root canal is achieved as described in the rst visit of the long-term apexication. Calcium hydroxide dressing is also indicated in order to raise the low pH of the inamed periapical tissue before the MTA placement. Lee et al. have demonstrated that an acidic environment has an adverse eect on the setting and micro hardness of MTA.18,96In the second visit, after rubber dam placement, the canal is irrigated and dried. After mixing according to the manufacturer’s instructions, a plug of MTA is compacted into the apical 4 to 5 mm of the canal, about 1 mm short of the radiographic apex (Fig. 34.6). Placement of MTA in the apical part is more complicated than the use of calcium hydroxide. e material is introduced into the apical area using special carriers or endodontic pluggers and compacted using hand condensation with indirect ultrasonic activation.97Placement of a resorbable material at the root end (e.g., calcium sulfate; CollaCote, Zimer Dental, Carlsbad, CA) against which the MTA can be compacted, keeping it within the connes of the canal space, has been suggested but does not seem necessary.98,99A BCD• Figure 34.6 (A) Immature mandibular molar with periapical pathologic radiolucent areas. (B) Apical plugs with mineral trioxide aggregate (MTA). (C) Warm gutta-percha lling over the hardened MTA plugs. (D) Successful follow-up after 15 months showing healing of the periapical lesions. (Courtesy Dr. E. Nuni.) CHAPTER 34 Pulp Therapy for the Young Permanent Dentition 493 be curved, so instrumentation should be done with precurved instruments in anticurvature ling motions. e use of nickel titanium (NiTi) rotatory instruments will ease the preparation of the root canal.IrrigationIrrigation during root canal treatment should be done only after making sure that the rubber dam is placed properly and that leakage of uids into the mouth cannot occur accidentally. e needle of the irrigation syringe is placed loosely in the root canal to avoid pushing the irrigation solution beyond the apex. NaOCl is used in various concentrations (0.5% to 5.25%) as the preferred irrigation solution.112Intracanal DressingIn teeth with infected root canals, the emphasis is on disinfection and removal of tissue remnants. Because eective mechanical preparation of wide canal walls is dicult, it is recommended that treatment be done in two sessions, with placement of an antiseptic dressing between visits. Calcium hydroxide paste is the preferred dressing material because it dissolves tissue remnants.88e placement of the dressing material can be accomplished using a Lentulo spiral shorter than the length of the root canal, specially designed syringes, or les.The Isthmuse isthmus is a thin communication between two or more root canals in the same root that contains pulp tissue. Any root containing two canals or more has a high incidence of isthmi.113An isthmus is formed when a root projection cannot close itself, and it will be larger in children where root formation is not fully complete. ese web-like connections between root canals are part of the root canal system. ey can function as a reservoir for bacteria and therefore should be cleaned and obturated during root canal treatment.113Obturatione apical foramen in young teeth is large, and adaptation of a master cone should be done carefully to avoid extrusion of lling materials that can easily occur during obturation. Lateral condensa-tion requires more accessory GP points; initial points should be placed such that they will not block access to the canal. Filling with warm GP or using warm condensation techniques should be done cautiously to avoid overlling.In some cases fabrication of a customized master cone is favor-able. A GP point is tted several millimeters short of the apex; the apical 2 to 3 mm are softened (with a solvent or a heat source) and tamped gradually into place. e completed customized cone represents an impression of the apical portion of the canal preventing extrusion of lling material during obturation.18References1. Mjor AI, Heyeraas KJ. Pulp-dentin and periodontal anatomy and physiology. In: Orstavik D, Pitt Ford TR, eds. Essential Endodontology. London: Blackwell; 1998.2. Smith AJ. Dentin formation and repair. In: Hargreaves KM, Goodis HE, eds. Seltzer and Bender’s Dental Pulp II. Carol Stream, IL: Quintessence; 2002.3. Cvek M. Prognosis of luxated non-vital maxillary incisors treated with calcium hydroxide and lled with gutta-percha. A retrospective clinical study. Endod Dent Traumatol. 1992;8:45–55.occurs in immature teeth after traumatic injury.100–103 When this treatment is successful, root lengthening and apical closure with thickening of the canal walls (maturogenesis) are expected, thus improving the long-term prognosis of the young tooth. A few factors are necessary for a successful endodontic regeneration. ese factors include absence of infection within the root canal space, a physical scaold, stem cells, signaling molecules, and an eective coronal seal.104,105e nature of the hard and soft tissue formed as a result of revascularization is not clear. Radiographic evidence of changes in root length and wall thickness does not necessarily indicate a regeneration of functional pulp tissue and the formation of new dentin and cementum. Histologic studies in dogs and humans suggest that in some cases these radiographic changes may be a result of deposition of cementum-like and bone-like tissues, meaning an ingrowth of PDL tissue instead of pulp tissue.18,105–109Techniquee rst step of the treatment is disinfection of the root canal space using irrigation solutions (like NaOCl) and an intracanal dressing (with a mix of antibiotics in a paste or calcium hydroxide).After disinfection, bleeding is introduced into the canal space through the apical foramen to create a scaold on which a new tissue will grow and repopulate the canal space. Alternatives such as platelet-rich plasma (PRP), platelet-rich fibrin (PRF), or autologous brin matrix (AFM) can also be used. Application of MTA or bioceramics and a good coronal seal is the last step of the treatment (see Chapter 35).110Advances in the eld of material sciences, stem cell biology, and dental tissue engineering have raised the possibility of using biology-based treatment strategies to regenerate functional dental tissues. In the short-term future, regeneration of an individual tooth structure is a more realistic approach than a regeneration of an entire tooth.111Nonvital Pulp Treatment for Young Mature TeethRoot Canal Treatment in Young Mature Permanent TeethSpecial ConsiderationsRoot canal treatment in mature teeth of children and adolescents is basically similar to that performed in adults. However, because of their wider canals and thinner dentin walls in comparison with those of adult patients, special precautions are needed, described as follows.Accesse coronal access should be wide enough to include the pulp horns to prevent future contamination and discoloration. During opening of the access cavity, care should be taken to remove only a minimal amount of dentin in the canal orices. Removing too much dentin will weaken anterior teeth and may cause perforation in molars.InstrumentationThe length of the root canal should be determined carefully using radiographs; an electronic apex locator or paper points can also be used. ough the root canals are larger, they may 494 Part 4 The Transitional Years: Six to Twelve Years30. Ogawa K, Yamashita Y, Ichijo T, et al. e ultrastructure and hardness of the transparent human carious dentin. J Dent Res. 1983;62(1):7–10.31. Maltz M, Garcia R, Jardim JJ, et al. Randomized trial of partial vs. stepwise caries removal. J Dent Res. 2012;91:1026–1031.32. Schwendicke F, Frencken JE, Bjorndal L, et al. Managing carious lesions: consensus recommendations on carious tissue removal. Adv Dent Res. 2016;28(2):58–67.33. Corralo D, Maltz M. Clinical and ultrastructural eects of dierent liners/restorative materials on deep carious dentin: a randomized clinical trial. Caries Res. 2013;47:243–250.34. Orhan AI, Oz FT, Orhan K. Pulp exposure occurrence and outcomes after 1- or 2-visit indirect pulp therapy vs complete caries removal in primary and permanent molars. Pediatr Dent. 2010;32:347–355.35. Ericson D, Zimmerman M, Raber H, et al. Clinical evaluation of ecacy and safety of a new method for chemo-mechanical removal of caries: a multi-centre study. Caries Res. 1999;33:171–177.36. Motta LJ, Bussadori SK, Campanelli AP, et al. Randomized controlled clinical trial of long-term chemo-mechanical caries removal using Papacarie gel. J Appl Oral Sci. 2014;22:307–313.37. American Academy of Pediatric Dentistry. Pulp therapy for primary and immature permanent teeth. Pediatr Dent. 2017;39:325–333.38. Brannstrom M. Communication between the oral cavity and the dental pulp associated with restorative treatment. Oper Dent. 1984;9:57–68.39. Browne RM, Tobias RS, Crombie IK, et al. Bacterial microleakage and pulpal inammation in experimental cavities. Int Endod J. 1983;16:147–155.40. Cox CF, Keall CL, Keall HJ, et al. Biocompatibility of surface-sealed dental materials against exposed pulps. J Prosthet Dent. 1987;57:1–8.41. Tziafas D, Kodonas K. Dierentiation potential of dental papilla, dental pulp, and apical papilla progenitor cells. J Endod. 2010;36:781–789.42. McDonald RE, Avery DR. Treatment of deep caries, vital pulp exposure, and pulpless teeth. In: McDonald RE, Avery DR, eds. Dentistry for the Child and Adolescent. Philadelphia: Saunders; 1994.43. Straon LH, Corpron RL, Bruner FW, et al. Twenty-four-month clinical trial of visible-light-activated cavity liner in young permanent teeth. ASDC J Dent Child. 1991;58:124–128.44. Levin LG, Law AS, Holland GR, et al. Identify and dene all diagnostic terms for pulpal health and disease states. J Endod. 2009;35:1645–1647.45. Massler M, Pawlak J. e aected and infected pulp. Oral Surg Oral Med Oral Pathol. 1977;43:929–947.46. Bjørndal L, Reit C, Bruun G, et al. Treatment of deep caries lesions in adults: randomized clinical trials comparing stepwise vs. direct complete excavation, and direct pulp capping vs. partial pulpotomy. Eur J Oral Sci. 2010;118:290–297.47. Bjørndal L, Larsen T, ylstrup A. A clinical and microbiological study of deep carious lesions during stepwise excavation using long treatment intervals. Caries Res. 1997;31:411–417.48. Bjørndal L, ylstrup A. A practice-based study on stepwise excavation of deep carious lesions in permanent teeth: a 1-year follow-up study. Community Dent Oral Epidemiol. 1998;26:122–128.49. Mertz-Fairhurst EJ, Adair SM, Sams DR, et al. Cariostatic and ultraconservative sealed restorations: nine-year results among children and adults. ASDC J Dent Child. 1995;62:97–107.50. Falster CA, Araujo FB, Straon LH, et al. Indirect pulp treatment: in vivo outcomes of an adhesive resin system vs calcium hydroxide for protection of the dentin-pulp complex. Pediatr Dent. 2002;24:241–248.51. Orhan AI, Oz FT, Ozcelik B, et al. A clinical and microbiological comparative study of deep carious lesion treatment in deciduous and young permanent molars. Clin Oral Investig. 2008;12: 369–378.52. Bergenholtz G. Eect of bacterial products on inammatory reactions in the dental pulp. Scand J Dent Res. 1977;85:122–129.4. Graham L, Cooper PR, Cassidy N, et al. e eect of calcium hydroxide on solubilisation of bio-active dentine matrix components. Biomaterials. 2006;27(14):2865–2873.5. Massagué J. e transforming growth factor-beta family. Annu Rev Cell Biol. 1990;6:597–641.6. Kuttler Y. Classication of dentin into primary, secondary and tertiary. Oral Surg. 1959;12:996–999.7. Howard C, Murray PE, Namerow KN. Dental pulp stem cell migration. J Endod. 2010;36:1963–1966.8. Cox CF, White KC, Ramus DL, et al. Reparative dentin: factors aecting its deposition. Quintessence Int. 1992;23:257–270.9. Lee SJ, Walton RE, Osborne JW. Pulp response to bases and cavity depths. Am J Dent. 1992;5:64–68.10. Murray PE, About I, Lumley PJ, et al. Postoperative pulpal and repair responses. J Am Dent Assoc. 2000;131:321–329.11. Murray PE, About I, Lumley PJ, et al. Cavity remaining dentin thickness and pulpal activity. Am J Dent. 2002;15:41–46.12. Belanger GK. Pulp therapy for young permanent teeth. In: Pinkham JR, ed. Pediatric Dentistry: Infancy rough Adolescence. Philadelphia: Saunders; 1999.13. Fuks AB, Heling I, Nuni E. Pulp therapy for the young permanent dentition. In: Casamassimo P, Fields H, McTigue D, et al, eds. Pediatric Dentistry: Infancy rough Adolescence. 5th ed. Elsevier Saunders; 2013:490–502.14. Fuss Z, Trowbridge H, Bender IB, et al. Assessment of reliability of electrical and thermal pulp testing agents. J Endod. 1986;12:301–305.15. Fulling HJ, Andreasen JO. Inuence of maturation status and tooth type of permanent teeth upon electrometric and thermal pulp testing. Scand J Dent Res. 1976;84(5):286–290.16. Johnsen DC, Harshbarger J, Rymer HD. Quantitative assessment of neural development in human premolars. Anat Rec. 1983;205:421–429.17. Perez R, Berkowitz R, McIlveen L, et al. Dental trauma in children: a survey. Endod Dent Traumatol. 1991;7(5):212–213.18. Nuni E. Pulp therapy for the young permanent dentition. In: Fuks AB, Peretz B, eds. Pediatric Endodontics. Switzerland: Springer International Publishing AG; 2016:117–148.19. Special Committee to Revise the Joint AAE/AAOMR Position Statement on use of CBCT in Endodontics. AAE and AAOMR Joint position statement: use of cone beam computed tomography in endondontics; 2015/2016 update. http://www.aae.org/uploadedles/clinical_resources/guidelines_and_position_statements/conebeamstatement.pdf. Accessed August 17, 2017.20. Slutzky-Goldberg I, Tsesis I, Slutzky H, et al. Odontogenic sinus tracts: a cohort study. Quintessence Int. 2009;40:13–18.21. Kadom N, Eglo A, Obeid G, et al. Juvenile mandibular chronic osteomyelitis: multimodality imaging ndings. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;111:38–43.22. Berman LH, Hartwell GR. Diagnosis. In: Cohen S, Hargreaves KM, eds. Pathways of the Pulp. St Louis: Mosby; 2006.23. Innes NPT, Frencken JE, Bjorndal L, et al. Managing carious lesions: consensus recommendations on terminology. Adv Dent Res. 2016;28(2):49–57.24. Fusyama T. e process and results of revolution in dental caries treatment. Int Dent J. 1997;47(3):157–166.25. Yoshiyama M, Tay FR, Doi J, et al. Bonding of self-etch and total etch adhesives to carious dentin. J Dent Res. 2002;81:556–560.26. Ten Cate JM. Remineralization of caries lesions extending into dentin. J Dent Res. 2001;80(5):1407–1411.27. Schwendicke F, Dörfer CE, Paris S. Incomplete caries removal: a systematic review and meta-analysis. J Dent Res. 2013;92:306–314.28. Ricketts D, Lamont T, Innes NPT, et al. Operative caries management in adults and children. Cochrane Database Syst Rev. 2013;(3):CD003808.29. Green D, Mackenzie L, Banerjee A. Minimally invasive long term management of direct restorations; the ‘5rs.’ Dent Update. 2015;42(5):413–426. CHAPTER 34 Pulp Therapy for the Young Permanent Dentition 495 77. Tziafas D, Molyvdas I. e tissue reactions after capping of dog teeth with calcium hydroxide experimentally crammed into the pulp space. Oral Surg Oral Med Oral Pathol. 1988;65(5): 604–608.78. Schröder U. Eect of an extra-pulpal blood clot on healing following experimental pulpotomy and capping with calcium hydroxide. Odontol Revy. 1973;24:257–268.79. Oginni AO, Adekoya-Sofowora CA, Kolawole KA. Evaluation of radiographs, clinical signs and symptoms associated with pulp canal obliteration: an aid to treatment decision. Dent Traumatol. 2009;25(6):620–625.80. Heide S, Kerekes K. Delayed partial pulpotomy in permanent incisors of monkeys. Int Endod J. 1987;20(2):65–74.81. Heling I, Gorl C, Slutzky H, et al. Endodontic failure caused by inadequate restorative procedures: review and treatment recom-mendations. J Prosthet Dent. 2002;87:674–678.82. Sheehy EC, Roberts GJ. Use of calcium hydroxide for apical barrier formation and healing in non-vital immature permanent teeth: a review. Br Dent J. 1997;11:183.83. Andreasen JO, Farik B, Munksgaard EC. Long-term calcium hydroxide as a root canal dressing may increase risk of root fracture. Dent Traumatol. 2002;18:134–137.84. Hatibović-Kofman S, Raimundo L, Zheng L, et al. Fracture resistance and histological ndings of immature teeth treated with mineral trioxide aggregate. Dent Traumatol. 2008;24(3):272–276.85. Fava LR, Saunders WP. Calcium hydroxide pastes: classication and clinical indications. Int Endod J. 1999;32:257–282.86. Kim D, Kim E. Antimicrobial eect of calcium hydroxide as an intracanal medicament in root canal treatment: a literature review—Part I. In vitro studies. Restor Dent Endod. 2014;39(4):241–252.87. Kim D, Kim E. Antimicrobial eect of calcium hydroxide as an intracanal medicament in root canal treatment: a literature review—Part II. in vivo studies. Restor Dent Endod. 2015;40(2):97–103.88. Hasselgren G, Olsson B, Cvek M. Eects of calcium hydroxide and sodium hypochlorite on the dissolution of necrotic porcine muscle tissue. J Endod. 1988;14:125–127.89. Rafter M. Apexication: a review. Dent Traumatol. 2005;21(1):1–8.90. Kleier DJ, Barr ES. A study of endodontically apexied teeth. Endod Dent Traumatol. 1991;7:112–117.91. van der Sluis LW, Versluis M, Wu MK, et al. Passive ultrasonic irrigation of the root canal: a review of the literature. Int Endod J. 2007;40(6):415–426.92. Metzger Z, Solomonov M, Mass E. Calcium hydroxide retention in wide root canals with aring apices. Dent Traumatol. 2001;17: 86–92.93. Seghi RR, Nasrin S, Draney J, et al. Root fortication. J Endod. 2013;39(3 suppl):S57–S62.94. Giuliani V, Bacccetti T, Pace R, et al. e use of MTA in teeth with necrotic pulps and open apices. Dent Traumatol. 2002;18:217.95. Abouqal R, Rida S. Apexication of immature teeth with calcium hydroxide or mineral trioxide aggregate: systematic review and meta-analysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;112(4):e36–e42.96. Lee YL, Lee BS, Lin FH, et al. Eects of physiological environments on the hydration behavior of mineral trioxide aggregate. Biomaterials. 2004;25(5):787–793.97. Yeung P, Liewehr FR, Moon PC. A quantitative comparison of the ll density of MTA produced by two placement techniques. J Endod. 2006;32:456–459.98. Trope M. Treatment of immature teeth with non-vital pulps and apical periodontitis. Dent Clin North Am. 2006;54(2): 313–324.99. Patino MG, Neiders ME, Andreana S, et al. Collagen as an implantable material in medicine and dentistry. J Oral Implantol. 2002;28(5):220–225.100. Andreasen JO, Borum MK, Andreasen FM. Replantation of 400 avulsed permanent incisors. 3. Factors related to root growth. Endod Dent Traumatol. 1995;11:69–75.53. Bergenholtz G. Inammatory response of the dental pulp to bacterial irritation. J Endod. 1981;7:100–104.54. Bergenholtz G, Cox CF, Loesche WJ, et al. Bacterial leakage around dental restorations: its eect on the dental pulp. J Oral Pathol. 1982;11:439–450.55. Warfvinge J, Dahlen G, Bergenholtz G. Dental pulp response to bacterial cell wall material. J Dent Res. 1985;64:1046–1050.56. Kitasako Y, Murray PE, Tagami J, et al. Histomorphometric analysis of dentinal bridge formation and pulpal inammation. Quintessence Int. 2002;33:600–608.57. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a compre-hensive literature review—Part I: chemical, physical, and antibacterial properties. J Endod. 2010;36(1):16–27.58. Tronstad L, Andreasen JO, Hasselgren G, et al. pH changes in dental tissues after root canal lling with calcium hydroxide. J Endod. 1981;7(1):17–21.59. Witherspoon DE. Vital pulp therapy with new materials: new directions and treatment perspectives-permanent teeth. Pediatr Dent. 2008;30(3):220–224.60. Schröder U. Eects of calcium hydroxide-containing pulp-capping agents on pulp cell migration, proliferation, and dierentiation. J Dent Res. 1985;64:541–548.61. Tziafas D. Basic mechanisms of cytodierentiation and dentinogenesis during dental pulp repair. Int J Dev Biol. 1995;39:281–290.62. Fuks AB, Heling I, Nuni E. Pulp therapy for the young permanent dentition. In: Casamassimo PS, Fields HW, McTigue DJ, et al, eds. Pediatric Dentistry: Infancy rough Adolescence. 5th ed. Philadelphia: Saunders; 2013:490–502.63. Tziafas D, Smith AJ, Lesot H. Designing new treatment strategies in vital pulp therapy. J Dent. 2000;28(2):77–92.64. Tziafas D, Pantelidou O, Alvanou A, et al. e dentinogenic eect of mineral trioxide aggregate (MTA) in short-term capping experi-ments. Int Endod J. 2002;35(3):245–254.65. Boutsioukis C, Noula G, Lambrianidis T. Ex vivo study of the eciency of two techniques for the removal of mineral trioxide aggregate used as a root canal lling material. J Endod. 2008;34(10): 1239–1242.66. Belobrov I, Parashos P. Treatment of tooth discoloration after the use of white mineral trioxide aggregate. J Endod. 2011;37(7): 1017–1020.67. Bogen G, Kim JS, Bakland LK. Direct pulp capping with mineral trioxide aggregate: an observational study. J Am Dent Assoc. 2008;139:305–315.68. Hilton TJ, Ferracane JL, Mancl L, et al. Comparison of CaOH with MTA for direct pulp capping: a PBRN randomized clinical trial. J Dent Res. 2013;92(suppl 7):16S–22S.69. Wang Z. Bioceramic materials in Endodontics. Endod Topics. 2015;32(1):3–30.70. Camp JH, Fuks AB. Pediatric endodontics: endodontic treatment for the primary and young permanent dentition. In: Cohen S, Hargreaves KM, eds. Pathways of the Pulp. St Louis: Mosby; 2006.71. Fuks AB. Pulp therapy for the primary and young permanent dentitions. Dent Clin North Am. 2000;44:571–596.72. Aguilar P, Linsuwanont P. Vital pulp therapy in vital permanent teeth with cariously exposed pulp: a systematic review. J Endod. 2011;37(5):581–587.73. Mente J, Geletneky B, Ohle M, et al. Mineral trioxide aggregate or calcium hydroxide direct pulp capping: an analysis of the clinical treatment outcome. J Endod. 2010;36:806–813.74. Qudeimat MA, Barrieshi-Nusair KM, Owais AI. Calcium hydroxide vs mineral trioxide aggregates for partial pulpotomy of permanent molars with deep caries. Eur Arch Paediatr Dent. 2007;8(2):99–104.75. Cvek M. A clinical report on partial pulpotomy and capping with calcium hydroxide in permanent incisors with complicated crown fracture. J Endod. 1978;4:232–237.76. Granath LE, Hagman G. Experimental pulpotomy in human bicuspids with reference to cutting technique. Acta Odontol Scand. 1971;29:155–163. 496 Part 4 The Transitional Years: Six to Twelve Years108. Becerra P, Ricucci D, Loghin S, et al. Histologic study of a human immature permanent premolar with chronic apical abscess after revascularization/revitalization. J Endod. 2014;40(1):133–139.109. Nazzal H, Duggal MS. Regenerative endodontics: a true paradigm shift or a bandwagon about to be derailed? Eur Arch Paediatr Dent. 2017;18(1):3–15.110. American Association of Endodontists. Guide to clinical endodontics. http://www.nxtbook.com/nxtbooks/aae/guidetoclinicalendodontics6/index.php#/12. Accessed February 12, 2018.111. Nor JE, Cucco C. e future: stem cells and biological approaches for pulp regeneration. In: Fuks AB, Peretz B, eds. Pediatric End-odontics. Swizerland: Springer International Publishing AG; 2016:117–148.112. Mohammadi Z. Sodium hypochlorite in endodontics: an update review. Int Dent J. 2008;58(6):329–341.113. Estrela C, Rabelo LE, de Souza JB, et al. Frequency of root canal isthmi in human permanent teeth determined by cone-beam computed tomography. J Endod. 2015;41(9):1535–1539.101. Banchs F, Trope M. Revascularization of immature permanent teeth with apical periodontitis: new treatment protocol? J Endod. 2004;30:196–200.102. Iwaya SI, Ikawa M, Kubota M. Revascularization of an immature permanent tooth with apical periodontitis and sinus tract. Dent Traumatol. 2001;17:185–187.103. Kling M, Cvek M, Mejare I. Rate and predictability of pulp revascularization in therapeutically reimplanted permanent incisors. Endod Dent Traumatol. 1986;2(3):83–89.104. Hargreaves KM, Giesler T, Henry M, et al. Regeneration potential of the young permanent tooth: what does the future hold? J Endod. 2008;34(suppl 7):S51–S56.105. Huang GT. Apexication: the beginning of its end. Int Endod J. 2009;42(10):855–866.106. Wang X, ibodeau B, Trope M, et al. Histologic characterization of regenerated tissues in canal space after the revitalization/revascularization of immature dog teeth with apical periodontitis. J Endod. 2010;36(1):56–63.107. ibodeau B, Teixeira F, Yamauchi M, et al. Pulp revascularization of immature dog teeth with apical periodontitis. J Endod. 2007;33(6):680–689. 49735 Managing Traumatic Injuries in the Young Permanent DentitionDENNIS J. MCTIGUECHAPTER OUTLINEEtiology and Epidemiology of Trauma in the Young Permanent DentitionClassication of Injuries to Young Permanent TeethHistoryClinical ExaminationPathologic Sequelae of Traumatized TeethTreatment of Traumatic Injuries to the Permanent DentitionEnamel FracturesEnamel and Dentin FracturesFractures Involving the PulpPosterior Crown FracturesRoot FracturesManaging Sequelae to Dental TraumaTreating Luxation Injuries in the Permanent DentitionSummaryEtiology and Epidemiology of Trauma in the Young Permanent DentitionFalls during play account for most injuries to young permanent teeth. Children engaging in contact sports are at greatest risk for dental injury, though the use of mouth guards greatly reduces their frequency (see Chapter 41). In the teenage years, auto-mobile accidents cause a signicant number of dental injuries when occupants not wearing seat belts hit the steering wheel or dashboard. As noted in Chapter 16, children with seizure disorders also injure their permanent teeth more frequently. In contrast to the primary dentition, permanent teeth suer crown fractures more frequently than luxation injuries. e lower crown/root ratio and denser alveolar bone in the permanent dentition contribute to this phenomenon. Maxillary central incisors are again most commonly injured, and protruding incisors are at greatest risk (Fig. 35.1).2Classication of Injuries to Young Permanent TeethClassication of tooth fractures and luxation injuries is discussed in Chapter 16 (see Fig. 16.1).Historye essential elements of the medical and dental history are discussed in Chapter 16. The use of a trauma assessment form to help organize the gathering of historical and clinical data is emphasized (see Fig. 16.8). e reader is reminded to determine the status of the child’s tetanus prophylaxis and to consult the child’s physician if there is any question about its adequacy.Another issue worthy of review relates to the potential for injury to the central nervous system. Older children are likely to suer harder blows at play, and thus the dentist should nd out if the child lost consciousness or became disoriented or nauseated after the injury. Positive ndings indicate immediate medical consultation. As noted in Chapter 16, signicant head injuries can lead to symptoms many hours after the initial trauma, and parents should be cautioned to watch for the signs noted previously for 24 hours, including waking the child every 2 to 3 hours throughout the night.3–5Injuries to the primary dentition are discussed in Chapter 16. Also covered there are the following fundamental areas relevant to managing trauma in children of any age:• Classicationoftraumaticinjuriestoteeth• Medicalanddentalhistory• Clinicalandradiographicexaminations• Commonreactionsofteethtotraumais chapter deals with injuries to the young permanent denti-tion, but the reader is strongly advised to review the fundamental areas just noted in Chapter 16. Frequent reference will be made to them.The reader is encouraged to review and use an excellent online resource, “e Dental Trauma Guide” (www.dentaltrauma guide.org),1 to assist in diagnosing and treating tooth injuries. is guide, developed by Dr. Jens O. Andreasen and sponsored in part by the University Hospital, Copenhagen, and the International Association of Dental Traumatology, contains updated guidelines on a broad array of injuries and is easy to use. 498 Part 4 The Transitional Years: Six to Twelve Years(inammatory) resorption. At 2 months, replacement resorption can be detected.13Cone beam computed tomography (CBCT) enables the clinician to view a three-dimensional image of a dental injury.14 e increased radiation, complexity, and cost of this procedure, however, con-traindicate its use in children for most dentoalveolar injuries. CBCT should be used only when the patient’s history and a clinical examination demonstrate that the benets to the patient outweigh the potential risks. e clinician should use CBCT only when the need for imaging cannot be met by lower dose two-dimensional radiography.Pathologic Sequelae of Traumatized TeethRefer to Chapter 16 for a discussion of the pathologic sequelae of traumatized teeth.Treatment of Traumatic Injuries to the Permanent Dentitione dentist treating a traumatic injury follows essentially the same principles of gathering historical information and completing a clinical examination, regardless of the child’s age. Furthermore, the pathologic sequelae of injuries to teeth are similar for both primary and permanent teeth. However, there are many signicant dierences in the way that injuries to permanent teeth are treated. As in the primary dentition, a complete diagnostic workup (described in Chapter 16) should precede all treatment. Even though a blow may cause little if any obvious injury to a permanent tooth, it may lead to pulp necrosis as a result of disruption of the neu-rovascular bundle at the apex of the tooth. Posttreatment evaluation is indicated for all traumatic injuries.Enamel FracturesIn some cases, minor enamel fractures can be smoothed with ne disks. Larger fractures should be restored using an acid-etch/composite resin technique (see Chapter 40 for restorative techniques).Enamel and Dentin Fracturese primary issue in managing fractures that expose dentin is to prevent bacterial irritants from reaching the pulp. Standard care in the past called for covering exposed dentin with calcium hydroxide Clinical ExaminationRefer to Chapter 16 for a thorough discussion of the clinical examination. An important dierence between the primary and permanent dentition exists in respect to “vitality” or sensibility testing. Whereas it is not routinely performed in the primary dentition, sensibility testing can be a useful diagnostic aid in the permanent dentition. e dentist should be aware that pulp testing might not elicit reliable responses from erupting permanent teeth and from those with open apices. Furthermore, recently traumatized teeth may not respond to any sensibility test for several months. Positive ndings immediately following a traumatic injury are thus more valuable for assessing pulp vitality than are negative responses.Cold testing with agents like diuorodichloromethane or carbon dioxide snow yields the most reliable results,6 although the thermal shock of the low temperature applied can cause infraction lines in the enamel.7 Some clinicians prefer electrical vitality testing because it uses a stimulus that can be gradually increased and precisely recorded. Using both cold tests and electric pulp tests provided the best sensitivity and specicity in a group of adult patients.8Pulp tests that use cold or electrical impulse do not actually measure “vitality” because that requires conrmation of uninter-rupted blood ow through the pulpal tissue. Instead, these tests measure neural response, which serves as a proxy for vascular health. Laser Doppler owmetry has potentially great clinical value because this technique directly measures blood ow and does not rely on sensory nerve response.9 is technique is also painless and is reliable in teeth with immature apices.10 However, modications in this instrument’s design and a signicant reduction in its cost are necessary for it to achieve widespread use. Another noninvasive technique that has potential diagnostic value is pulse oximetry, which measures blood oxygen saturation in the vessels monitored.11,12 Although there is currently no commercial product available, future technological advances will enable development of aordable devices that attach to teeth and will give the clinician a better measure of tooth vitality.Principles of radiographic diagnosis for permanent teeth do not dier from those for primary teeth. A common error made by dentists in diagnosing traumatic injuries is to take an insucient number of radiographs. Additional views taken from slightly dierent angles both vertically and horizontally can signicantly improve the accuracy of diagnosis.13It is important to note the urgency of follow-up radiographs after injury. Reviewing radiographs at 1 month after injury will detect signs of pulpal necrosis and rapidly progressing AB• Figure 35.1 (A) Lateral view showing large horizontal overjet. (B) Same patient with fractured central incisors. (From McTigue DJ. Management of orofacial trauma in children. Pediatr Ann. 1985;14: 125–129.) CHAPTER 35 Managing Traumatic Injuries in the Young Permanent Dentition 499 It is important to note that root end closure does not signal completion of root maturation. Progressive deposition of dentin normally continues in roots through adolescence, making them stronger and more resistant to traumatic insult. Maintaining a vital pulp in the tooth crown allows the clinician to monitor the tooth’s vitality periodically.It is not always possible to maintain vital tissue throughout the tooth. ree treatment alternatives are available, based on the clinical ndings just noted:1. Direct pulp cap2. Pulpotomy3. PulpectomyDirect Pulp Cape direct pulp cap is only indicated in small exposures that can be treated within a few hours of the injury. e chances for pulp healing decrease if the tissue is inamed, has formed a clot, or is contaminated with foreign materials. e objective, then, is to preserve vital pulp tissue that is free of inammation and physiologi-cally walled o by a calcic barrier.A rubber dam is applied, and the tooth is gently cleaned with water. Commercially available CaOH paste or mineral trioxide aggregate (MTA) is applied directly to the pulp tissue and to surrounding dentin.17 It is essential that a restoration be placed that is capable of thoroughly sealing the exposure to prevent further contamination by oral bacteria. As in the management of dentin fractures, it is acceptable to use an acid-etch/composite resin system for an initial restoration. A calcic bridge stimulated by the capping material should be evident radiographically in 2 to 3 months. While MTA for direct pulp caps has been reported to be as successful as CaOH,18 signicant discoloration of the tooth crown can occur with its use (see Fig. 34.2).19In fractures exposing pulps of immature permanent teeth with incomplete root development, a direct cap is no longer the treatment of choice. Failure in these cases leads to total pulpal necrosis and a fragile, immature root with thin dentinal walls. us the preferred treatment in pulp exposures of immature permanent teeth is pulpotomy.Pulpotomye objectives of the pulpotomy technique are to remove only the inamed pulp tissue and to leave healthy tissue to enhance physi-ologic maturation of the root. As previously noted, this technique is favored for immature permanent teeth with exposed pulps. It is also indicated in large exposures or for pulps exposed for more than a few hours. Owing to its higher success rate, many clinicians (CaOH) or glass ionomer cement to seal out oral ora. Sealing exposed dentin with a bonding agent enables the unexposed pulp to form reparative dentin. Some clinicians have then advocated simultaneous acid etching of dentin and enamel, followed by dentin and enamel bonding without placement of CaOH or glass ionomer.15 However, a review of pulp capping with dentin adhesive systems reported that these systems are not indicated owing to increased inammatory reactions, delay in pulp healing, and failure of dentin bridge formation.16 is author recommends covering the deepest portion of dentin fractures with glass ionomer cement, followed by a dentin-bonding agent (see Chapters 22 and 40). e tooth can then be restored with an acid-etch/composite resin technique (Fig. 35.2). If adequate time is not available to restore the tooth completely, an interim covering of resin material (a resin “patch”) can temporize the tooth until a nal restoration can be placed. Some dentists routinely place such a partial restoration to ensure an appropriate posttreatment evaluation when the patient returns for the nal restoration. is is a reasonable strategy, provided that care is taken to ensure an adequate seal. Another option may be to immediately re-bond a fractured segment to the injured tooth. Refer to Chapter 40 for a description of this technique.Fractures Involving the Pulpe management of crown fractures that expose the pulp is par-ticularly challenging (Fig. 35.3). Pertinent clinical ndings that dictate treatment include the following:1. Vitality of the exposed pulp2. Time elapsed since the exposure3. Degree of root maturation of the fractured tooth4. Restorability of the fractured crowne objective of treatment in managing these injuries is to preserve a vital pulp in the entire tooth (see Chapter 34). is allows for physiologic closure of the root apex in immature teeth. BA• Figure 35.2 A fractured incisor (A) can quickly be restored using an acid-etch/composite resin tech-nique (B). • Figure 35.3 Crown fracture exposing the pulp. 500 Part 4 The Transitional Years: Six to Twelve YearsMTA has been shown to perform well in pulpotomies, causing dentinal bridge formation while maintaining normal pulpal his-tologic features.22,23 As noted previously, however, its tendency to stain teeth is a clinical concern.19 See Chapter 34 for details on its use.PulpectomyA pulpectomy involves complete pulp tissue removal from the crown and root and is indicated when no vital tissue remains. It is also indicated when root maturation is complete and the per-manent restoration requires a post buildup. In the absence of rapidly progressing (inammatory) root resorption, treatment is to obturate the canal with gutta-percha. e reader is referred to standard endodontic textbooks for more information on this technique.One of the greatest challenges facing the clinician is the treatment of a nonvital immature permanent tooth with an open apex. Physiologic root maturation cannot occur without the presence of vital pulp tissue, apical papilla stem cells, odontoblasts, and the Hertwig epithelial root sheath.24 Traditional treatment for these cases was an apexication procedure wherein CaOH was carried to the root apex to contact vital tissues directly. e CaOH stimu-lated the formation of a cementoid barrier against which gutta-percha could subsequently be condensed. Multiple visits over a period of 9 to 18 months were required, however, and the outcome was a shortened root with thin walls (Fig. 35.7).25 In addition, long-term CaOH therapy has been shown to weaken the tooth root and increase the likelihood of root fractures.26An alternative to the CaOH apexication technique for managing devitalized immature incisors is the apical barrier technique using MTA.27 e material is condensed into the apical area and allowed have totally abandoned the direct pulp cap in favor of pulpotomy.It is dicult to determine clinically how far the inamed pulp extends. e tooth shown in Fig. 35.4 had been fractured for 4 days with a pulp exposure approximately 3 mm in diameter. e dentist elected to remove all tissue in the pulp chamber, with obvious success. Fig. 35.4B demonstrates complete maturation of the root, including apical closure and dentinal wall thicken-ing, as well as a calcic barrier at the amputation site. However, maintaining some pulp tissue in the crown allows the dentist to monitor the vitality of the tooth and thus is preferable when possible.In 1978, Cvek noted that in most cases of pulps exposed for more than a few hours, the initial biological response is pulpal hyperplasia.20 Inammation in these cases rarely extends beyond 2 mm. In his study involving 60 teeth with pulps exposed from 1 hour to 90 days, Cvek removed only 2 mm of the pulp and the surrounding dentin. He covered the pulp stumps with CaOH and reported a success rate of 96%. e long-term success reported by Fuks and colleagues conrms these ndings and indicates that this conservative removal of tissue is the treatment of choice (Figs. 35.5 and 35.6).21Absolute isolation to prevent contamination of the pulp with oral bacteria is essential. e inamed pulp is gently removed to a level approximately 2 mm below the exposure site with a sterile diamond bur at high speed. Copious irrigation is mandatory to avoid pulp injury. e preparation should provide adequate space for the CaOH or MTA pulp dressing and a glass ionomer seal. Attaining a bacteria-tight coronal seal is essential for the success of this technique. e tooth can then be esthetically restored with composite resin.A B• Figure 35.4 (A) Crown fracture exposing the pulp in an immature permanent incisor. Note the open apex and thin dentinal walls in the root. (B) A calcium hydroxide pulpotomy stimulated the formation of a calcic barrier (arrow) and enabled the root to mature, demonstrating apical closure and root wall thickening. CHAPTER 35 Managing Traumatic Injuries in the Young Permanent Dentition 501 AB• Figure 35.5 (A) Maxillary right permanent central incisor suffered crown fracture with pulp exposure. (B) One-year postoperative radiograph of the same tooth successfully treated with a calcium hydroxide partial pulpotomy. Note completion of root development both apically and laterally. to set. Gutta-percha is then condensed against the MTA barrier at a subsequent appointment (Fig. 35.8). ough overall treatment time is greatly reduced, the shortened root and thin walls continue to place the tooth at risk for subsequent cervical root fracture.Regenerative EndodonticsIwaya, Hoshino, and others reported a dramatic alternative to apexication of necrotic immature teeth termed revascularization or “regenerative” endodontics.28–30 ese procedures seek to replace damaged dentin, root structures, and pulp cells with live tissues that restore normal physiologic function.31 e concept is to thoroughly disinfect the root canal system and then stimulate bleeding from the apical papilla to ll the root chamber with a blood clot. A host of growth factors in the area then act on dental stem cells, primarily from the apical papilla, to use the clot as a scaold and dierentiate into healthy cells of the pulp-dentin complex that can complete physiologic root maturation.e technique (Fig. 35.9) is to rst cleanse the canal by copious irrigation with sodium hypochlorite or ethylenediaminetetraacetic acid (EDTA).32 Owing to the immature status of the root and thin radicular walls, instrumentation is kept to a minimum and used mainly to agitate the irrigant. e irrigant is also activated AB CED• Figure 35.6 Partial pulpotomy technique. (A) Complicated crown fracture of the maxillary right central incisor, exposing the pulp. (B) Removing pulp to a depth of 2 mm with sterile diamond bur. (C) Blood clot after pulp amputation. (D) Calcium hydroxide base on pulp stump. (E) Glass ionomer seal. (Courtesy Dr. Ashok Kumar.) 502 Part 4 The Transitional Years: Six to Twelve Yearspaste or CaOH is rinsed out, and a sterile endodontic le is placed beyond the apex to initiate bleeding. A clot is allowed to form as close to the CEJ as possible to facilitate root thickening at the tooth cervix. MTA is then placed against the clot, and the tooth is temporarily sealed with glass ionomer cement. e nal restoration is placed at a subsequent appointment. Root maturation should be apparent radiographically within several months (Fig. 35.10).Regenerative endodontics is still an emerging eld and no evidence-based guidelines are available to inform the clinician about its precise indications or technique. More research will rene the technique and will undoubtedly lead to its greater use in the future.Criteria for SuccessCriteria to judge success of the techniques used to manage pulpal insult in fractured teeth include the following:• Completionofrootdevelopmentinimmatureteeth• Absenceofclinicalsignssuchaspain,mobility,orstula• Absenceofanyradiographicsignsofpathologicprocesses,suchas periapical radiolucency of bone or root resorptionPosterior Crown FracturesPosterior crown fractures in the permanent dentition pose a restorative challenge for the clinician. ese fractures usually occur secondary to hard blows to the underside of the chin, and vertical crown fractures may result (Fig. 35.11). Although bonding with posterior composite resins is sometimes possible, full coverage with stainless steel or cast metal crowns is often the only restorative alternative. e reader is reminded to watch for mandibular fractures and cervical spine injuries in these cases.36Root Fracturese prognosis for root fractures is best when the fracture occurs in the apical one-third of the root. e prognosis worsens progres-sively with fractures that occur more cervically in the root. Bender and Freedland reported that more than 75% of teeth with intraalveolar root fractures maintain their vitality.37• Figure 35.7 An apexication procedure allowed this immature perma-nent tooth to be obturated successfully with gutta-percha (GP). The root, however, remains fragile and at increased risk of future trauma because no further dentinal wall apposition can occur. A CB• Figure 35.8 Apexication using apical barrier technique. (A) Preoperative view. (B) Four-week postop-erative view. (C) Twenty-seven-month postoperative view. by placing an ultrasonic tip about 3 mm short of the working length in the canal to facilitate better debridement of the pulp tissue remnants and to minimize the substrate for microbial prolifera-tion. e canal space is then dried using sterile paper points. A low concentration triple antibiotic paste of ciprooxacin, metro-nidazole, and minocycline is carefully placed into the canal with a Lentulo spiral up to the cementoenamel junction (CEJ).29 Owing to its tendency to stain teeth, minocycline is often replaced with clindamycin.33,34 CaOH is also sometimes used in lieu of the antibiotic paste, again to avoid tooth discoloration.35 e access cavity is sealed with a sterile cotton pellet and glass ionomer cement.e patient is scheduled for a follow-up appointment after 3 to 4 weeks. At the follow-up appointment, the area is anesthetized with local anesthetic containing no epinephrine. e antibiotic

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