Clinical Evaluation of a Fissure Sealant Placed by Acid

Etching or Er:YAG Laser Combined with Acid Etching

Basak Durmusa / Figen Eren Giraya / Sertac Pekerb / Betul Kargulc

Purpose: To evaluate the efficacy of conventional acid etching alone (acid etching) and Er:YAG laser combined with
acid etching (laser + acid etching) on fissure sealant (FS) retention of first permanent molars (FPMs) after 18
months.
Materials and Methods: Using a split-mouth design in 51 children, a total of 204 FPMs were sealed with acid etching
alone or laser plus acid etching (laser+acid). The retention of sealants and occurrence of caries were evaluated at
3, 6, 12, and 18 months. Statistical analysis was performed using Pearson’s chi-squared tests.
Results: The retention rate for FS in the laser+acid group was significantly higher than that of the acid-etch group
at 12 (p = 0.0161) and 18 (p = 0.0227) months. Six FSs in the acid group and five FSs in the laser+acid group
were completely lost after 18 months. The incidence of caries in the acid-etch group was 22% (n = 18) vs 10%
(n = 8) in the laser+acid group at 18 months. The difference in caries development between the groups was not
significant (p > 0.05).
Conclusions: As enamel pretreatment, Er:YAG laser combined with acid etching significantly improves FS retention
over conventional acid etching alone.
Key words: dental acid etching, lasers, pit and fissure sealants

Oral Health Prev Dent 2017; 15: 157–162. Submitted for publication: 08.12.14; accepted for publication: 20.11.15
doi: 10.3290/j.ohpd.a37927

I n recent years, dentistry has focused on preventive pro-

cedures and reducing caries risk.5 Although only 12.5% of
all tooth surfaces are occlusal, more than two-thirds of caries
in children develop on these surfaces.34 The most appro-
priate and cost-effective treatment for the prevention of oc-
clusal caries in children at high risk is the application of
pit-and-fissure sealants.3,15 Sealants help to control caries
by forming a physical barrier that prevents metabolic ex-
change between fissure microorganisms and the oral envi-
ronment.3,24,37
Although sealants have been shown to be successful
preventive restorations, it is rare for them to be retained
completely over the lifetime of the tooth. Even when applied
appropriately, 5%–10% of sealants can be expected to fail
annually.16 Several clinical studies have indicated that the
a Associate Professor, Department of Paediatric Dentistry, Faculty of Dentistry,
Marmara University, Istanbul, Turkey. Performed the clinical treatment, wrote
the manuscript, read and approved the final manuscript.
b Associate Professor, Department of Paediatric Dentistry, Faculty of Dentistry,
Marmara University, Istanbul, Turkey. Drafted and proofread the manuscript,
read and approved the final manuscript.
c Professor, Department of Paediatric Dentistry, Faculty of Dentistry, Marmara
University, Istanbul, Turkey. Study design, drafted and proofread the manu-
script, read and approved the final manuscript.
Correspondence: Basak Durmus, Department of Paediatric Dentistry, Faculty of
Dentistry, Marmara University, Buyukçiftlik Sok. No:6 Kat:4, Nisantasi, Istanbul,
Turkey. Tel: +90-216-421-1621-1540; Email: altinokbasak@yahoo.com
success of FSs depends on the sealant retention, the main-
tenance of sealant integrity, and the properties of the seal-
ant material.26,37,38
Retention rates vary according to the proper isolation
of the working field, viscosity of the sealant material,
preparation of enamel surfaces, and use of an adhesive
system.36 The use of phosphoric acid is a well accepted,
standard method for roughening enamel surfaces. Unfor-
tunately, conditions are not always optimal, and organic
remnants as well as fissure morphology and aprismatic
enamel structure can reduce etching performance and thus
compromise adhesion.12 Saliva contamination is a fre-
quently faced problem after pretreatment of the enamel
with phosphoric acid to create microporosites for retention.
When the microporosites are coated with saliva, the reten-
tion and effectiveness of the fissure sealants are jeop-
ardised.31 Concerns raised due to the disadvantages of
acid etching, which include technical sensitivity and isola-
tion problems,11,30-32 have led researchers to focus on al-
ternative methods for sealant retention, such as enamelo-
plasty, an air-polishing system, or laser treatment.4
The use of erbium:yttrium-aluminum-garnet (Er:YAG) laser
irradiation for dental applications has become increasingly
widespread since FDA approval in 1997, and its use for
pretreatment and surface conditioning in pit-and-fissure
sealing has since been under discussion.4,14,20,27 The
laser irradiation of hard dental tissue modifies the calcium:

Vol 15, No 2, 2017 157

Durmus et al
phosphorus ratio, reduces the carbonate:phosphate ratio,
and leads to the formation of more stable and less acid-
soluble compounds, thus reducing susceptibility to acid
attacks and caries.10,13 It is also thought to have an anti-
bacterial effect by trapping free ions and forming remineral-
isation microspaces.6,10 Furthermore, tooth isolation is not
required for this procedure. With all these beneficial features,
this technique seems to be promising for overcoming the
problems faced during fissure sealant application. However,
studies on the quality of FSs following Er:YAG laser prepar-
ation are scarce and not conclusive.5,22
Therefore, the aim of this 18-month clinical study was to
evaluate the efficacy of two enamel pretreatment methods
– conventional acid etching alone and Er:YAG laser condi-
tioning in combination with acid etching – on sealant reten-
tion on FPMs.
MATERIALS AND METHODS
The proposed approach was a randomised cohort study
approved by Yeditepe University Ethics Commitee (AUG-
YC-2011-0131) and performed in accordance with the ethi-
cal standards laid down in the 1964 Declaration of Helsinki
and its later amendments.
Considering the power of the study to be 80% and the
effect size 5%, the required sample size was evaluated to
be 94 teeth each in the experimental and control groups.
To compensate for possible dropouts, we started the study
with 102 participants each in the laser acid groups.
The participants consisted of 51 children (27 boys and
24 girls, aged 7–10 years (mean age 8.14 ± 0.88 years),
categorised as high caries risk (dmft: 4-6), with all four
newly erupted, caries-free, untreated FPMs attending the
Department of Paediatric Dentistry, University of Marmara
(Istanbul, Turkey). Individual caries risk was based on the
dmft index of each patient with caries registered at the cav-
itation level at the visit of FS placement, which was consid-
ered the initial visit for the purposes of the study. All seal-
ant placements were performed by the same trained and
experienced paediatric dentist (F.E.G). At each follow-up
visit, the children were examined by two calibrated staff
members (B.D., S.P.) in a dental chair with reflector light,
air-water spray, and a mirror.
All patients were advised to follow a preventive pro-
gramme that included oral hygiene instructions, use of
fluoridated toothpaste and diet counselling.
Clinical Procedures
Prior to the clinical procedure, each child and parent were
informed about the protocol of the study, and written in-
formed consent was obtained. A total of 204 maxillary and
mandibular FPMs were sealed by the same paediatric den-
tist (F.E.G.) in 51 patients under the split-mouth design.
Prior to sealant application, the teeth were carefully iso-
lated with cotton rolls and a flexible plastic saliva ejector to
prevent saliva contamination. The fissures of the teeth
were cleaned with a prophylaxis brush using a nonfluori-
158
dated pumice (Nada Pumice paste, Patterson Dental Sup-
ply; St Paul, MN, USA) to remove salivary pellicle and any
remaining plaque.
Study Groups
In group 1 (acid-etch group), the fissures of teeth #16 and
#46 (n = 102) were etched with 35% phosphoric acid (Voco-
cid, VOCO; Cuxhaven, Germany) for 30 s, rinsed for 15 s,
and dried for a few seconds until the surfaces were chalky
white. In group 2 (laser-plus-acid-etch group [laser+acid]),
the fissures of teeth #26 and #36 (n = 102) were irradiated
with an Er:YAG laser system (Fotona Medical Lasers, Fidelis
PLUS Er:YAG Dental Laser; Ljubljana, Slovenia) using a non-
contact handpiece (R02) with the following settings: wave-
length: 2.94 μm; power: 2 W; energy output: 120 mJ; short
pulse duration (SP); frequency: 10 Hz; and a beam spot
size of 0.6 mm. Air and water sprays from the handpiece
were adjusted to prevent the enamel surface from overheat-
ing. The laser beam was aligned perpendicular to the fis-
sure in noncontact mode at a distance of 1 to 2 mm in ac-
cordance with the manufacturer’s instructions for etching.
The duration of exposure depended on the time needed to
guide the laser beam evenly across the pits and fissures to
be irradiated. Following laser irradiation, the fissures were
also etched with 35% phosphoric acid using the same pro-
cedure as in group 1.
Following pretreatment, all teeth were rinsed, air dried,
and sealed with a light-curing, highly filled, fluoridated nano-
hybrid fissure sealant (Grandio Seal, VOCO) and were light
cured for 20 s (Bluephase C5, Ivoclar Vivadent; Schaan,
Liechtenstein). After the materials were placed on the pits
and fissures, the occlusion was checked with articulating
paper. Any premature contacts were removed using fine-grit
round diamond burs (Dia-Burs, MANI; Tochigi, Japan) to en-
sure that the sealant material did not produce occlusal in-
terference. The material surfaces were polished with rubber
cups (Polydentia; Mezovicco, Switzerland).
Clinical Evaluation
Two experienced clinicians (S.P., B.D.), who were unaware
of which preparation method had been used, evaluated the
restorations at 3-, 6-, 12- and 18-month follow-up visits.
They reached a consensus if their findings differed. Sealant
retention and caries occurrence were evaluated in terms of
caries formation (present or absent), and retention was
classified as completely retained (CR), partial loss (PL), or
total loss (TL) using Simonsens’s criteria.28 The ‘completely
retained’ sealant category did not address sealant wear. If
some peripheral fissures were uncovered following sealant
wear, but no ledges were present, the sealant was classi-
fied as completely retained (ledges indicate bulk loss of
some adjacent sealant). A score of ‘partially loss’ was given
when, following either wear or material loss, part of a previ-
ously sealed pit/fissure was exposed. ‘Total loss’ signified
that no trace of sealant was detectable (Fig 1).28 In the
event of partial or total loss, the FSs were replaced or re-
paired, and those teeth were eliminated from the study.
Oral Health & Preventive Dentistry

Statistical Analysis
The results were recorded and analysed using the statis-
tical software package SPSS v. 16.0.0 for Windows (SPSS;
Chicago, IL, USA). The Kappa values were high (0.95), indi-
cating considerable intra- and interexaminer agreement. Any
discrepancy between evaluators was resolved chairside.
Pearson’s chi-squared test was used to evaluate differ-
ences in the retention rates of the sealant between the two
pretreatment methods for each evaluation period at a 5%
level of significance.
RESULTS
Fifty-one patients participated in this clinical study, of which
42 were available for all evaluations, resulting in a recall rate
of 83%. A total of 168 restorations (84 acid-etch, 84
laser+acid) were evaluated at the 18-month follow-up. The
complete retention rate after 18 months was 58% for the
acid-etch group and 77% for the laser+acid group. After 3
months, there was a partial loss of 6 sealants (7%) in the
acid group and 3 (4%) in the laser+acid group. After
6 months, there were 12 (14%) partial losses in the acid-etch
group and 6 (7%) in the laser+acid group. There were 3 total
losses of sealant with both techniques. After 12 months,
there were 25 (30%) partial losses of sealant in the acid-etch
group and 10 (12%) in the laser+acid group. The retention
rates for FS in the laser+acid group were significantly higher
at 12 (82%, p = 0.0161) and 18 months (77%, p = 0.0227)
when compared with the acid-etch group. After 18 months,
there was a complete loss of 6 FSs in the acid-etch group and
5 FSs in the laser+acid group. There were no significant differ-
ences in retention rates between these two preparation meth-
ods after 3 and 6 months (p = 0.4878, p = 0.3109) (Table 1).
The sealants were better retained on the maxillary mo-
lars, but this difference was not statistically significant
(p > 0.05) (Tables 2 and 3).
After 18 months, the incidence of caries in the acid
group was 22% (n = 18) versus 10% (n = 8) in the
laser+acid group. The difference in caries development after
18 months between the two methods was not statistically
significant (p > 0.05). Among the treated teeth, the caries
incidence on the mandibular first molars was higher than on
the maxillary first molars; however, this difference was not
statistically significant at 12 or 18 months (p > 0.05).
Vol 15, No 2, 2017
Durmus et al
Fig 1 Clinical photos of fissure sealent
retention at 18 months. A. Completely
retained; B. partial loss.
DISCUSSION
The current study compared the efficacy of using an Er:YAG
laser combined with conventional acid etching vs conven-
tional acid etching as pretreatment for FS in young FPMs of
children over an 18-month period.
The use of rubber-dam for isolation of the operating field
is well documented in the literature, and has been reported
to significantly improve sealant retention rates.17,36 How-
ever, some studies have found that retention rates of FSs
and composite resin restorations placed using rubber-dam
or cotton roll isolation are similar.2,34 Therefore, in this
study, the operating field was isolated using cotton rolls
and a plastic saliva ejector to prevent saliva contamination
during the procedure.
Surface conditioning procedures may affect the retention
and preventive effects of FSs in clinical approaches.29,34
The pretreatment of enamel with various concentrations of
phosphoric acid is a conventional method that has certain
disadvantages; therefore, other methods such as laser
etching of enamel surfaces have gained popularity.25,27
However, there have been some contradictory findings con-
cerning the use of lasers for enamel etching. Lepri et al20
reported that the use of an Er:YAG laser (80 mJ, 2 Hz) did
not improve the efficacy of conventional acid etching of
enamel in the bonding of sealants, nor was the laser help-
ful in overcoming the negative effects of salivary contamina-
tion. Abou El-Yazeed et al1 reported that Nd:YAG laser
(400 mJ, 10 Hz) conditioning and the application of laser
followed by acid etching appeared to have identical efficacy
and were superior to acid etching alone in the sealing of
pits and fissures. Moreover, Baygın et al4 (Er,Cr:YSGG laser
2W, 20 Hz) and Shahabi et al27 (Er:YAG laser 100 mJ,
10 Hz) reported that laser etching may constitute an alter-
native to conventional acid etching, but that laser etching
did not eliminate the need for acid etching prior to place-
ment of a FS. Stereomicroscopic observation revealed that
the laser completely cleaned debris in pits and fissures,
having the advantage of reaching the narrowest, deepest
parts of the fissures.18 Therefore, those authors concluded
that the removal of debris accumulated in fissures could
improve sealant retention.
These contradictory findings may be due to the different
output characteristics of lasers and experimental designs
of the studies, as stated by Karaman et al.19 Furthermore,
159
Durmus et al

Table 1 Distribution of sealant retention rates

Evaluation time 3 months 6 months 12 months 18 months

Acid Laser+acid Acid Laser+acid Acid Laser+acid Acid Laser+acid

Completely retained n (%) 76 (91%) 80 (95%) 69 (81%) 75 (89%) 54 (65%) 69 (82%) 49 (58%) 65 (77%)

Partial loss n (%) 6 (7%) 3 (4%) 12 (15%) 6 (7%) 25 (29%) 10 (12%) 29 (35%) 14 (17%)

Total loss n (%) 2 (2%) 1 (1%) 3 (4%) 3 (4%) 5 (6%) 5 (6%) 6 (7%) 5 (%6)

p = 0.4878 p = 0.3109 p = 0.0161* p = 0.0227*

*Statistically significant at p < 0.05.

Table 2 Distribution of sealant retention rates in the acid-etched group for maxillary and mandibular molars

Evaluation 3 months 6 months 12 months 18 months

Tooth No. 16 46 16 46 16 46 16 46

Completely retained n (%) 37 (88%) 39 (93%) 36 (86%) 33 (79%) 29 (69%) 25 (60%) 26 (62%) 23 (55%)

Partial loss n (%) 4 (10%) 2 (5%) 5 (12%) 7 (17%) 10 (24%) 15 (36%) 13 (31%) 16 (38%)

Total loss n (%) 1 (2%) 1 (2%) 1 (2%) 2 (2%) 3 (7%) 2 (4%) 3 (7%) 3 (7%)

p = 0.6979 p = 0.6713 p = 0.4732 p = 0.7811

Table 3 Distribution of sealant retention rates in the laser+acid group for maxillary and mandibular molars

Evaluation 3 months 6 months 12 months 18 months

Tooth No. 26 36 26 36 26 36 26 36

Completely retained n (%) 39 (93%) 41 (98%) 36 (86%) 39 (93%) 34 (81%) 35 (83%) 33 (79%) 32 (76%)

Partial loss n (%) 3 (7%) 0 (0%) 4 (10%) 2 (5%) 5 (12%) 5 (12%) 6 (14%) 8 (19%)

Total loss n (%) 0 (0%) 1 (2%) 2 (4%) 1 (2%) 3 (7%) 2 (5%) 3 (7%) 2 (4%)

p = 0.1320 p = 0.5712 p = 0.8983 p = 0.7784

laser and conventional etching were compared only with
respect to marginal leakage under ex vivo conditions. The
effect of laser etching on sealant retention in vivo has been
evaluated in only a few studies,8,19,35 so that it is difficult
to compare the present and previous findings.
In a split-mouth clinical trial comparing the retention of
FSs placed using CO2 laser or acid etching, the retention
rates were statistically similar after a mean follow-up period
of 14.5 months.35 Furthermore, a 4-year follow-up in vivo
controlled study demonstrated that use of a laser on oc-
clusal fissures prior to application improved the retention of
a photoactivated FS.8 In a recent study, Karaman et al19
compared the 24-month clinical performance of a FS placed
using several enamel preparation methods. They concluded
that 83.9% of the sealants in the laser group and 85.7% in
the acid-etch group were completely retained; there was no
statistically significant difference in retention rates between
the preparation methods at any evaluation period.
The current study found statistically significant differ-
ences between the retention rates of the acid-etch group
(65%, 58%) and the laser+acid group (82%, 77%) after 12
and 18 months, respectively. Therefore, these results are
in accordance with previous reports in which a combination
of laser irradiation and acid etching was compared with con-
ventional acid-etching treatment.5,8,18,27 However, one ex-
planation for the present lower rates in overall retention
during a shorter follow-up period might be that initial caries
risk status in children was positively associated with sealant
failure in FPMs. Other studies7,23 also reported that reten-
tion decreased with increasing caries risk, agreeing with the
present study, where high caries risk was associated with
higher rate of FS failure.7,23 Furthermore, it seems reason-

160 Oral Health & Preventive Dentistry


able to assume that tooth selection or technique failure at
the time of sealant placement were responsible for the ma-
jority of partial or total losses within the first six months of
placement.21 This was most likely due to inadequate mois-
ture control.
Possible reasons for partial and total losses in the laser-
pretreatment group have been discussed previously.4,30
The first is that that the Er:YAG laser does not create a
uniform etching pattern, unlike that obtained with acid etch-
ing; instead, laser ablation yields a random fragmentation
and removal of dental substance with cleavage along
enamel prisms. In addition, the beam is not emitted con-
tinuously; therefore, non-lased areas are created between
the laser pulses. Such an irregular microstructure likely
leads to bonding failures and undermines marginal sealing.
Therefore, the present results support the statement of Vi-
jayaraghavan et al33 that Er:YAG laser irradiation of pits and
fissures does not eliminate the need for etching.
Higher partial and total sealant loss rates and caries for-
mation were observed in mandibular vs maxillary molars at
the end of the observation period. This finding may be re-
lated to fissure morphology and the difficulties of isolation,
leading to saliva contamination, on the mandibular molars.
Fissure morphology may influence the application and reten-
tion of sealants. Shallow fissures tended to show fewer
unfilled areas than deep fissures, probably because sealant
penetration and adaptation are achieved more readily in
wide-angle fissures. As stated by Ciucchi et al,12 it may be
easier for the clinician to eliminate trapped air bubbles from
shallow fissures than from deep fissures, as the dental
probe or brush is betteer able to reach the bottom of shal-
low fissures to dislodge any air pockets.
At the beginning of the study, there were no cavitated
carious lesions on the selected molars. However, incipi-
ent enamel lesions were detected at 18 months in 22% of
the acid-etch group and 10% of the laser+acid group. This
is likely attributable to the fact that in high-caries–risk,
caries-active children, the occlusal enamel of the pits and
fissures was already undergoing tissue structure changes
before FS application, which might have altered the prop-
erties of the enamel surface.9,23 Therefore, although etch-
ing is presumed to occur on sound, healthy enamel, this
is not always true. The higher organic content of this
questionable surface might hinder acid penetration into
deeper layers and prevent the homogeneous etching of
the enamel. As a result of insufficient bonding, the FS
retention decreases and caries initiation is inevitable.9,23
The same studies 9,23 found that a relatively steady rate
of caries development occurred regardless of resealing,
especially in a high-caries group. Although the difference
in caries development between the etching methods at
18 months was not statistically significant, the caries pro-
gression rate was lower in the laser+acid group. One rea-
son for this may be that laser irradiation reduces the
carbonate:phosphate ratio, which leads to the formation
of more stable, less acidic soluble compounds. 30,32
Several benefits of laser irradiation were demonstrated
in the current study, such as the creation of an acid-resis-
Vol 15, No 2, 2017
Durmus et al
tant surface and improved sealant retention at the 18-
month follow-up. However, the economic aspect of sealant
application must also be considered. Sealant application
has to remain simple, rapid, and affordable to be used as a
prophylactic measure. Although laser treatment followed by
acid etching improves the retention of FSs compared to
acid etching alone, when the extra time and cost of equip-
ment and materials required are taken into consideration,
the cost:benefit ratio appears to be questionable.12 Never-
theless, the results of this in vivo study suggest that
laser+acid pretreatment is a good choice for the prepar-
ation of enamel prior to the application of a FS.
CONCLUSION
The results of our study indicate that, at the end of an
18-month period, fissure sealants placed with Er:YAG
laser treatment combined with acid etching showed sig-
nificantly higher retention rates than those placed with
conventional acid etching alone. However, caries devel-
opment rates were similar in both groups. Considering
the potential benefits associated with the laser system,
further studies should be conducted to confirm the repro-
ducibility of these findings.
Regardless of the preparation method used before seal-
ant placement, the FS retention decreases over time and
caries initiation is inevitable. Therefore, sealants should only
be placed after careful diagnosis of caries risk and – given
high risk – simultaneous implementation of intensified, su-
pervised oral hygiene measures or prophylaxis impulses.
ACKNOWLEDGEMENT
We would like to thank Prof. Dr. Nural Bekiroglu (Department of Bio-
statistics and Bioinformatics, School of Medicine, Marmara Univer-
sity, Istanbul, Turkey) for her statistical expertise.
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