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A two-year evaluation of four different fissure sealants

Article  in  European Archives of Paediatric Dentistry. Official Journal of the European Academy of Paediatric Dentistry · April 2010
DOI: 10.1007/BF03262718 · Source: PubMed

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A two-year evaluation of four different
fissure sealants
Y. Yılmaz*, N. Beldüz*, O. Eyüboglu**
Dept. of Paedodontics, Faculty of Dentistry, Atatürk University, Erzurum,**Private Practice, Trabzon; Turkey
Abstract
AIM: To evaluate fissure sealants based on Bis-GMA [Fis-
surit F (FF) and Fissurit FX (FFX)], compomer [Dyract Seal
(DS)] and ormocer [Admira Seal (AS)] with respect to reten-
tion, marginal integrity and presence of caries after a 2-year
period of follow-up. METHODS: 80 children aged 7-13 years
(mean age: 9.4±1.3 years), were included, giving a total of 320
first permanent molars for the study units. Clinical evaluation
of the sealants was carried out to assess retention, marginal
integrity and presence of caries at 12 and 24 months after
initial treatment. RESULTS: Retention of compomer-based
DS sealant was significantly lower than that of the others
at the 12- and 24-month follow-up examinations (12 month,
P<0.000; 24 month, P<0.006). No significant differences
between the sealants were observed in marginal integrity (12
month, P>0.473; 24 month, P>0.069) or presence of caries
(12 month, P>0.055; 24 month, P>0.777) at any follow-up
examination. CONCLUSION: While sealants composed of
different resin matrices showed differences in retention, they
were similar with respect to marginal integrity and presence
of caries. Surface conditioning and the organic structure of
the material are factors that may affect sealant retention.
Introduction
Caries diagnosis in the occlusal pit and fissures plays a cru-
cial role for a successful fissure sealant (FS) treatment [Feigal,
1998]. Diagnostic methods for dental caries such as visual-
tactile assessment, visual inspection, visual inspection with
magnification, laser fluorescence DIAGNOdent and bite-
wing radiographs have been used [Erten et al., 2006]. Visual
inspection may lead to an incorrect treatment decision for
teeth with deep pit and fissures and a sharp dental explorer
used in the visual-tactile assessment may damage the dem-
ineralised areas and lead to implantation of microorganisms
[McComb et al., 2001]. Caries of the occlusal enamel may
not clearly be visible on radiographs because of the super-
imposition of the buccal and lingual enamel. However, visual
inspection with magnification and DIAGNOdent were able to
both increase the sensitivity of diagnosis of caries and were
more effective than the other types of examination [Erten et
al., 2006].
The composition of FS is important to their success [Feigal,
1998]. Materials such as polyurethane, cyanoacrylate resins,
glass ionomer cements, Bis-GMA resins, polyacid-modified
Key words: Sealants, organic structure, filler, retention, caries prevention, marginal integrity
Postal address: Dr. Y. Yilmaz. Dept. of Paedodontics 25240, Atatürk University, Faculty of Dentistry, Erzurum, Turkey.
Email: yyilmaz25@atauni.edu.tr
88
European Archives of Paediatric Dentistry // 11 (Issue 2). 2010
composite resins (compomers) and ormocers have been
used as FS [Rugg-Gunn, 2001]. Bis-GMA-based FS have
been widely used in preventive dentistry [Rugg-Gunn,
2001]. It has been reported that Bis-GMA-based FS have
good mechanical properties and are capable of simulating
the tooth structure [Manhart et al., 2000]. Bis-GMA-based
FS have some disadvantages, such as a low rate of fluoride
release, and require an acid conditioning procedure prior to
the application of the FS [Kugel, 2000].
Compomer materials have been developed in order to elimi-
nate these disadvantages [Gungor et al., 2004]. The use of a
compomer FS with a non-rinse conditioner is able to prevent
both contamination of oral tissues and potential disruptive
behaviours caused by rinsing of the tooth after acid-etching.
Compomers have the desirable mechanical and optical prop-
erties of both composite resins and glass-ionomer cements,
and release an adequate amount of fluoride [Powers, 2002].
Gungor et al. [2004] found that FSs based on compomer
materials and Bis-GMA had similar retention rates; in con-
trast, Ram et al. [2005] showed that compomer FS had lower
rates of success than Bis-GMA-based FS.
In 1998 a new restorative material, ormocer, which is based
on silicon dioxide, was introduced to the market [Hickel et
al., 1998]. Ormocers, in contrast to resin-based compos-
ites, are composed of larger monomer molecules that can
reduce the effects of polymerization shrinkage, wear and
leaching of monomer (the oestrogenic chemical bisphenol-
A) [Arenholt-Bindslev et al., 1999; Bottenberg et al., 2007].
Although several previous studies have evaluated the clinical
properties of ormocers when they are used as a restorative
material [Tagtekin et al., 2004], no study evaluating the use
of ormocers as a FS could be found in the literature. The
aim of this study was, therefore, to evaluate the differences
between FS based on Bis-GMA, compomer, and ormocer in
terms of the criteria of retention, marginal integrity and pres-
ence of caries over a 2-year period of follow-up.
Materials and Methods
Study design. This was as a randomized single blind clini-
cal trial to compare the clinical criteria of retention, marginal
integrity and presence of caries of sealants based on Bis-
GMA, compomer, and ormocer used to seal permanent first
permanent molars [FPMs] over a 2-year period. Each child

and parent was informed of the protocol of the study, and
parental informed consent was obtained before the applica-
tion of FS.
Subjects. The study participants were 80 healthy children (36
girls, 44 boys), cooperative Frankl score 3 or 4 [Wright, 2000]
aged 7 to 13 years (mean age: 9.4±1.3 years) who were
referred to the Paedodontics Department of the Dentistry
Faculty, Ataturk University, Turkey. The selection criteria for
the study participants were:
l Residence in the same geographical region,
l Theabsence of bruxism, malocclusion, or allergy to
dental resins or latex,
l The presence of fully erupted FPMs with deep and reten-
tive pits and fissures,
l The presence of caries-free FPMs.
The evaluation of caries was performed using an intraoral
camera (760,000 pixels, D60204449 RF System, Japan)
and a DIAGNOdent device (DiagnoDent, KaVo, Biberach,
Germany).
Assessment of teeth. The plaque and debris on the occlusal
surfaces were removed using a rotating brush without proph-
ylaxis paste. Images of the teeth were then captured using
an intraoral camera and recorded on a computer. Images
were evaluated according to the caries criteria of Frances-
cut and Lussi [2003] on a 17-inch computer monitor by one
previously trained researcher (YY). The scoring system was
calibrated using 20 randomly selected teeth chosen within
the criteria required for this study. A maximum of 30 sec was
allowed for the examination of each tooth. Teeth were then
isolated with cotton rolls and assessed in terms of caries
by the same researcher (YY) using a DIAGNOdent device.
This device was calibrated using a ceramic plate and the
tooth surface under investigation. Teeth that showed DIAG-
NOdent readings of more than 20 as a cut-off point were not
included in the study, according to the instructions of the
manufacturer. In all 320 FPMs from the 80 participants were
included in the study. Although the required sample size was
114 (power analysis=0.80), the study was performed on 320
samples. The number of maxillary and mandibular FPMs in
each FS group was equal
Fissure sealant Application. Each tooth was isolated with
standard cotton rolls and the occlusal surface was dried. FS
with different organic structures as described in Table 1 [two
Bis-GMA (FF and FFX), one ormocer (AS) and one compomer
(DS)] were applied by two experienced operators. All steps
of FS application were performed according to the manufac-
turer’s recommendations. The two Bis-GMA-based FS (40
participants, 160 FPM applications) were applied in a split
mouth design. Ormocer-based FS (20 participants, 80 FPM
applications) and compomer-based FS (20 participants, 80
FPM applications) were randomly applied. The randomiza-
tion procedure for the FS was performed using a series of
consecutively numbered randomization envelopes.
Evaluation of four fissure sealants
After the application of FS, occlusion was checked with a
carbon marker. Any premature contacts were removed using
a round bur. A fluoride varnish was applied to the demate-
rialized area that had been caused by acid etching. Images
of the FS were then captured with the intraoral camera and
recorded on the computer.
Fissure sealant evaluation. FS were evaluated clinically by
one researcher (YY) with respect to the criteria of reten-
tion, marginal integrity and presence of caries at follow-up
examinations performed 12 and 24 months after treatment
[Gungor et al., 2004]. During the follow-up examinations,
images of the FS were captured using the intraoral camera.
The marginal integrity of the FS was assessed using a dental
explorer. Evaluation of the retention and presence of caries
was performed by matching the first and follow-up pictures
of the FSs.
Statistical Analysis. The data were analyzed using the SPSS
11.0 statistics program for Windows at the 5% significance
level. The difference between the ages of the participants
who were treated with different types of FS was analyzed
using one-way ANOVA. A chi-square test was used to com-
pare the differences among the four different sealants and
to determine which group or groups was responsible for any
differences.
All FS were assessed for retention, marginal integrity and
presence of caries using the alpha bravo, charlie septom. In
this system alpha indicated full retention; bravo some reten-
tion and charlie – lost FS. Caries was assessed as alpha – no
caries and bravo – caries present
Results
Intra-examiner was reliability calculated for each evaluation
criterion using the kappa statistic for intra-examiner reli-
ability it was calculated as 0.80: 0.86 for retention, 0.72 for
marginal integrity, and 0.82 for presence of caries. There was
no statistically significant difference in the age of the partici-
pants among the FS groups (P>0.83). The distribution of the
evaluation scores of the FS by time following treatment is
shown in Table 2. Table 3 shows the clinical condition of the
FS during the follow-up examinations. In all 7 children were
lost to the first follow-up: they were either not interested in
further participation or had moved abroad. At the end of the
last clinical evaluation period, 99 of 292 FS had failed.
There were statistically significant differences between FSs
for retention criteria at all follow-up examinations, and the
difference was found to be due to the low retention rate of
the DS group (Table 2). The differences between FS with
respect to both marginal integrity and presence of caries
were not statistically significant at any follow-up examina-
tion (Table 2).
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European Archives of Paediatric Dentistry // 11 (Issue 2). 2010
Y. Yılmaz et al.

Table 1: Fissure sealant materials and applications used in the study

Material/Code (Manufacturer) Composition/Colour Procedure

Vococid 34.5% phosphoric acid gel
(Voco, Cuxhaven, Germany)
FF Bis-GMA, diurethane dimethacylate,
(Voco, Cuxhaven, Germany) BHT, benzotriazolderivate, 1.3% sodium
fluoride, low filled (9.5%) /opaque white
FFX Bis-GMA, diurethane dimetacrylate,
(Voco, Cuxhaven, Germany) BHT, benzotriazolderivate, 1.0% sodium
fluoride, highly filled (55%) /opaque white
AS Three-dimensionally curing inorganic
(Voco, Cuxhaven, Germany) –organic co-polymers as well as additive
aliphatic and aromatic dimethacrylates, highly
filled (54%)/opaque white
NRC Itaconik and maleic acid, water
(Dentsply De Trey, Konstanz, Germany)
Prime-Bond NT Di and trimethacrylate resins, PENTA,
(Dentsply De Trey, Konstanz, Germany) UDMA resins, photoinitiators,
cetylamine hydrofluoride, acetone
DS Aminopenta, macromonomer, DGDMA, aerosil,
(Dentsply De Trey, Konstanz, Germany) inhibitor, initiators, strontium-aluminum-fluorosil-
icate glass, app. 35% filled /clear
Application: Apply for 60 s, remove by using
air–water spray
Etching: Used Vococid
Application: Apply and allow to penetrate for
15–20s, then light-cured for 30s
Etching: Used Vococid
Application: Apply and allow to penetrate for
15–20s, then light-cured for 30s
Etching: Used Vococid
Application: Apply and allow to penetrate for
15–20s, then light-cured for 30s
Application: Apply and leave undisturbed for
20s then remove by blowing gently
Application: Apply for 20s, remove by blowing
gently for 5s
Etching: Used NRC
Application: After Prime-Bond NT was applied,
DS was placed immediately and light-cured for
40s

Table 2: The distribution of evaluation scores of the sealants related to the follow-up periods.

Criteria Time Scores FF FFX DS AS Chi-square / P

12 months Alpha 19 (29%) 21 (32%) 8 (11%) 24 (33%)
Bravo 45 (69%) 42 (65%) 60 (80%) 44 (60%) 16.591
Charlie 1 (2%) 2 (3%) 7 (9%) 5 (7%) P<0.011*
Total 65 65 75 73
Retention
24 months Alpha 18 (29%) 14 (22%) 5 (7%) 17 (25%)
Bravo 39 (63%) 41 (67%) 50 (75%) 47 (70%) 15.416
Charlie 5 (8%) 7 (11%) 12 (18%) 3 (5%) P<0.017*
Total 62 62 67 67
12 months Alpha 34 (52%) 29 (44%) 27 (36%) 36 (49%)
Bravo 29 (45%) 35 (54%) 47 (63%) 36 (49%) 5.567
Charlie 2 (3%) 1 (2%) 1 (1%) 1 (2%) P>0.473

Marginal Total 65 65 75 73
integrity 24 months Alpha 31 (50%) 25 (40%) 20 (30%) 24 (36%)
Bravo 20 (32%) 25 (40%) 38 (57%) 37 (55%) 12.269
Charlie 11 (18%) 12 (20%) 9 (13%) 6 (9%) P>0.056
Total 62 62 67 67
12 months Alpha 62 (95%) 64 (99%) 74 (99%) 66 (90%) 7.758
Bravo 3 (5%) 1 (1%) 1 (1%) 7 (10%) P>0.051

Presence Total 65 65 75 73
of caries 24 months Alpha 55 (89%) 52 (84%) 60 (90%) 58 (86%) 1.099
Bravo 7 (11%) 10 (16%) 7 (10%) 9 (14%) P>0.772
Total 62 62 67 67
Significant differences between the groups were determined with a chi-square test (*P< 0.05 significant difference) – DS values were the reason of the differences

90
European Archives of Paediatric Dentistry // 11 (Issue 2). 2010

Table 3: Clinical evaluation of the fissure sealant materials after 1 and 2 years.
Sealant Successful
N
Materials 12 mths
FF 68 62
FFX 68 62
DS 80 67
AS 76 67
Total 292 258
Teeth with a Charlie score for the retention or marginal integrity criteria, or a bravo score for the presence of caries were evaluated as failed.
Discussion
It has been claimed that FS minimize the harmful effects of
cariogenic microorganisms on the surface of tooth enamel
by producing an effective mechanical barrier against the
plaque. This study evaluated the clinical success of 4 FS
that contained 3 different resin matrices. Stepped margins
of FS contribute to the accumulation of plaque [Ganss et al.,
1999], therefore, marginal integrity is an important criterion
in the evaluation of FS. In the evaluation of marginal integ-
rity, the differences between FS, that have different organic
structures and filler rates have been found to be statisti-
cally insignificant. Gungor et al. [2004] demonstrated lower
marginal integrity scores for a compomer-based FS when
compared with Bis-GMA-based FSs at 12-month follow-up,
but similar marginal integrity scores between FS were found
at a 24-month follow-up. The latter result was in accordance
with our findings. No previous clinical studies have been per-
formed to investigate ormocer-based FS.
Inorganic filler component is another factor that is associ-
ated with marginal integrity [Simonsen, 2002]. Although the
difference was not significant, the highest alpha score rates
for marginal integrity in this study were noted in the low-filled
FS (FF). This is in agreement with Koch et al. [1997], who
stated that an increase of the inorganic filler rate causes poor
marginal adaptation due to a lower wetting ability of the FS.
Although there were no carious lesions on the study teeth at
baseline, caries was detected in 54 of the 292 FPMs during
the study. Fractured or partially lost FS leave deep fissures
uncovered or a sharp margin that may lead to the formation
of caries [Feigal, 1998]. In the present study, FS materials
were only applied once and prevention against caries pro-
vided by FS decreases over time if they are applied with this
regimen [Llodra et al., 1993; Gomez et al., 2005]. There was
no statistically significant difference found among the FS for
caries. Interestingly, although low retention was noted in the
DS group, this group showing similar caries when compared
with the other treatment groups at all follow-up examina-
tions. This may be explained in several ways: firstly, while
compomer-based materials release an intermediate level
of fluoride, Bis-GMA- and ormocer-based FS release only
a low level [Kugel, 2000]. Tanaka et al. [1987] have stated
that the incorporation of fluoride into the enamel underly-
ing or adjacent to the sealant increases the resistance to
Evaluation of four fissure sealants
Failed Lost to Follow-up
24 mths 12 mths 24 mths 12 mths 24 months
43 3 19 0 0
46 3 16 0 0
46 8 21 0 0
58 6 9 0 0
193 20 65 0 0
demineralisation. Secondly, the antibacterial effect of Prime
& Bond NT, the one-step self-etching primer, may contribute
to prevention of caries. It has been claimed that the antibac-
terial effect of dentine bonding systems may be related to
their chemical composition or low pH [Baseren et al., 2005].
However, Prime & Bond NT does not contain antibacterial
components such as glutaraldehyde and 12-methacryloy-
loxydodecyl-pyridinium bromide (MDPB). Therefore, the
antibacterial effect of Prime & Bond NT could be attributed
to its low pH of 1.86, which was calculated in a laboratory
medium using a pH/ISE meter (model: 730P, ISTEK, Seoul,
Korea).
There was a statistically significant difference between FS for
retention. The DS group showed a considerably lower retention
rate than other FS. Surface conditioning may have had a sig-
nificant effect on retention, because a non-rinse conditioning
procedure was used in the DS group, following the manu-
facturer’s guidelines. This finding is in agreement with Yakut
and Sonmez [2006] and Ram et al. [2005] who reported a low
retention rate for DS used with a non-rinse conditioner. Fuks
et al. [2002] found that when phosphoric acid was used, the
bond strength of a DS FS was much higher than that of NRC +
Prime & Bond NT. However, they reported that DS with phos-
phoric acid showed slightly lower shear bond strength than a
Bis-GMA-based sealant. Therefore, another factor that affects
FS retention may be the compomer organic structure of DS.
Rock et al. [1990] and later Yildiz et al. [2004] stated that the
rate and type of inorganic filler were factors that influenced
the retention of FS. However, it appears that the rate and
type of filler could not have had an influence on the retention
rates of the FS in the present study because FS with differ-
ent rates and types of inorganic filler showed similar retention
rates. In the present study, three (FF, FFX and AS) of the four
FS showed similar results with respect to retention, marginal
integrity and the presence of caries. The fourth sealant (DS)
presented a different result at the 12- and 24-months follow-
up examinations with respect to retention criteria.
Visual inspection with magnification and laser fluorescence
DIAGNOdent diagnostic systems were used prior to the
application of FS to prevent their placement over carious
areas. It has been reported that the use of intraoral cam-
eras and the DIAGNOdent diagnostic system can aid clinical
91
European Archives of Paediatric Dentistry // 11 (Issue 2). 2010
Y. Yılmaz et al.
decision-making [Erten et al., 2006]. The operators in this
study were meticulous in avoiding the placement of FS over
carious areas.
The first and follow-up pictures of FS were evaluated
according to the criteria of retention and presence of car-
ies to improve the accuracy of the evaluations. However, the
evaluations of marginal integrity were performed using visual
and tactile assessment, as in previous studies, because the
marginal integrity cannot be evaluated from images of the
teeth [Gungor et al., 2004]. The DIAGNOdent system was
not used for caries detection in the sealed fissures at follow-
up examinations because it does not work on opaque FS
[Simonsen, 2002]. Although the clear type of DS was used,
the DIAGNOdent device was not used for the assessment of
caries for this FS to obtain a standardized approach.
This study focused on the clinical effectiveness of FS that
have different inorganic filler rates and organic structures
when used to seal clinically sound pits and fissures. Further
clinical studies are required in order to evaluate sealants that
have chemically different resin matrices with respect to the
evaluation criteria used in this study.
Conclusion
While fissure sealants with different resin matrices showed
differences in retention, there were no difference among
sealants with respect to marginal integrity and the presence
of caries. Surface conditioning and the organic structure of
the sealant may be factors that influence sealant retention.
Acknowledgement:
This research was supported by the Department of Science Research
Projects, Ataturk University.
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