COMPARATIVE EVALUATION OF RETENTION AND LONGEVITY OF TWO NON-FLUORIDATED PIT AND FISSURE

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COMPARATIVE EVALUATION OF RETENTION AND LONGEVITY OF TWO NON-FLUORIDATED PIT AND FISSURE

SEALANTS PLACED WITH AND WITHOUT USE OF BONDING AGENTS IN YOUNG PERMANENT MOLARS AFFECTED BY

DENTAL FLUOROSIS - AN IN - VIVO STUDY.

Dissertation submitted to

THE TAMILNADU Dr. M.G.R. MEDICAL UNIVERSITY

In partial fulfillment for the degree of MASTER OF DENTAL SURGERY

BRANCH – VIII

PEDODONTICS AND PREVENTIVE DENTISTRY

THE TAMILNADU Dr. M.G.R. MEDICAL UNIVERSITY CHENNAI – 600032

2016 – 2019

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ACKNOWLEDGEMENT

Before setting out to thank everyone who moulded me, I owe everything of my existence to the ALMIGHTY and MY PARENTS.

My sincere thanks and deep sense of gratitude to my Dean Prof.

Capt. Dr. S. GOKULANATHAN, B.Sc., M.D.S., Vivekananda Dental College for Women, for permitting me to pursue this Main Dissertation.

With submissive ambition, I aspire to register my gratitude to my respected Principal Dr. N. BALAN. M.D.S., Vivekananda Dental College for Women, or permitting me to pursue this Main Dissertation.

I respect and thank, Dr. V. MaheshMathian, M.D.S., Professor and Head, Department of Pedodontics and Preventive Dentistry, Vivekanandha dental college for women for his constant encouragement and expert guidance without whom this submission wouldn’t have been feasible.

With submissive ambition, I aspire to register my gratitude to my respected Mentor and Guide Dr. S. Vinodh, M.D.S., Reader, Department of Pedodontics and Preventive Dentistry, Vivekanandha dental college for women for his inspiring guidance, invaluable counsel and encouragement throughout the course of the Main Dissertation.

I thank Dr. M. Manoharan, M.D.S., without whom this work would

not have seen the light of the day without his affectionate and

compassionate counseling, which reposed by confidence in myself to

complete this work.

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I am thankful to the faculty members of our department for helping me in completing this work Dr. M. Gawthaman, M.D.S., Professor, Dr.

Patil Disha, M.D.S., Dr. Philomine Princy M.D.S., and Dr. R. Rajkumar Senior Lecturer’s for their support and encouragement in this work.

I am thankful to Prof. Dr. Girish R Shavi M.D.S., Dr. Om Prakash Yadav M.D.S., for their statistical guidance in obtaining results.

I’m thankful to my batchmates Preethi Archana.S and Ramyalakshmi.I.K, for their kind co-operation during the main dissertation and the entire course would be futile.

I acknowledge my senior’s Gaytry.S.S, Kamatchi.M and KiruthigaRevathy.A, as well my juniors Anjugam. P, Dhivya. S, Menaka.E.K., Gayathrikumary.T, Yamunadevi.E.S. and Sharon Maria.E for their support and encouragement

A special and worthy note of thanks is extended to the non-teaching staff of the Department of Pedodontics and Preventive Dentistry, VDCW.

I earnestly thank my loving Family members for all the pains they have taken, without whom entering this profession would have been nothing more than a dream. Special thanks to my beloved Guru’s in & out of dentistry who have been constantly supporting me and heartfelt thanks to my beloved Friends and Juniors.

Dr. NIRANJANA.A

Post Graduate Student.

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Contents

LIST OF TABLES

S.NO CONTENTS PAGE NO

Table 1 Sealant materials 27

Table 2 Mascarenhas.et.al. criteria (2008) 34

Table 3

Retention rates among Group I (HELIOSEAL) and Group II (FISSURIT) fissure sealant materials at 1 week, 1, 3, 6 and 12 months.

42

Table 4

Comparison of Group I (HELIOSEAL) and Group II (FISSURIT) with respect to retention at 1 week, 1, 3, 6 and 12 months by Mann–Whitney U test.

43

Table 5

Comparison of Group IA (HELIOSEAL) and Group IIA (FISSURIT) with respect to retention at 1 week, 1, 3, 6 and 12 months by Mann–

Whitney U test.

43

Table 6

Comparison of Group IA (With Bonding Agent) and Group IB (Without Bonding Agent) in HELIOSEAL Sealant with respect to retention at 1 week, 1, 3, 6 and 12 months by Mann–Whitney U test

44

Table 7

Comparison of Group II A (With Bonding Agent) and Group II B (Without Bonding Agent) in FISSURIT Sealant with respect to retention at 1 week, 1, 3, 6 and 12 months by Mann–Whitney U test

45

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Contents

Table 8

Comparison of Group IB (HELIOSEAL) and Group IIB (FISSURIT) with respect to retention at 1 week, 1, 3, 6 and 12 months by Mann–

Whitney U test

46

Table 9 Retention rates among sub groups at 1 week, 1,

3, 6 and 12 months 47

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Contents

LIST OF FIGURES

Figure 1 Armamentarium for Group IA 28

Figure 2 Armamentarium for Group IB 28

Figure 3 Armamentarium for Group IIA 29

Figure 4 Armamentarium for Group IIB 29

Figure 5 Armamentarium for Isolation 30

Figure 6 Armamentarium for Polishing 30

Figure 7 Armamentarium for Review 31

Figure 8 Pre-OP Photographs of Maxillary and Mandibular

Arch. 33

Figure 9 Post-OP Photographs of Maxillary and Mandibular

Arch. 33

Figure10 Application of sealants. 34

Figure 11 Acid Etching. 35

Figure 12 Application of Bonding Agent 35

Figure 13 Light curing of Bonding agent 35

Figure 14 Application of sealants 36

Figure 15 Application of sealants Group I &Group II 36 Figure 16 Evaluation of sealants during intervals. 37

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Contents

Figure 17 Evaluation of sealants Score 1. 37

Figure 20 Evaluation of sealants during intervals. 39 Figure 21 Evaluation of sealants during 1week intervals. 39 Figure 22 Evaluation of sealants during 1month intervals. 40 Figure 23 Evaluation of sealants during 3 month intervals. 40 Figure 24 Evaluation of sealants during 6 month intervals. 41 Figure 25 Evaluation of sealants during 12 month intervals. 41

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Contents

LIST OF GRAPHS

Graph 1

Retention rates among Group I (HELIOSEAL) and Group II (FISSURIT) fissure sealant materials at 1 week, 1, 3, 6 and 12 months.

48

Graph 2

Comparison of Group I (HELIOSEAL) and Group II (FISSURIT) with respect to retention at 1 week, 1, 3, 6 and 12 months by Mann–Whitney U test.

48

Graph 3

Comparison of Group IA (With Bonding Agent) and Group IB (Without Bonding Agent) in HELIOSEAL Sealant with respect to retention at 1 week, 1, 3, 6 and 12 months by Mann–Whitney U test.

49

Graph 4

Comparison of Group IIA (With Bonding Agent) and Group IIB (Without Bonding Agent) in FISSURIT Sealant with respect to retention at 1 week, 1, 3, 6 and 12 months by Mann–Whitney U test.

49

Graph 5

Comparison of Group IA (HELIOSEAL) and Group IIA (FISSURIT) with respect to retention at 1 week, 1, 3, 6 and 12 months by Mann– Whitney U test.

50

Graph 6

Comparison of Group IB (HELIOSEAL) and Group IIB (FISSURIT) with respect to retention at 1 week, 1, 3, 6 and 12 months in by Mann– Whitney U test.

50

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Contents

LIST OF ABBREVIATIONS

S.NO Abbreviation Explanation

1. FS Fissure Sealants

2. HC Helioseal Clear

3. HF Helioseal F

4. GI Glass Ionomer

5. RMGI Resin-modified Glass Ionomer

6. RBS Resin Based Sealant

7. Bis-GMA Bisphenol A-glycidyl methacrylate 8. CST Conventional Sealant Technique 9. EST Enameloplasty Sealant Technique 10. SEM Scanning Electron Microscopy 11. LRBS Light Cured Resin-Based Sealants 12. ARBS Auto-Polymerized Resin-Based Sealants 13. FRBS Fluoride Contained Resin-Based Sealants

14. FS Formerly Sealed

15. NS Never-Sealed

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Contents

16 SBDS School Based Dental Sealant

17. DBA Dentin Bonding Agent

18. TAE Traditional Acid Etching

19. SE Self-Etching

20. Er,Cr:YSGG Erbium, Chromium: Yttrium Scandium- Gallium-Garnet

21. ES Eruption Stages

22. MB Methylene Blue

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Abstract

ABSTRACT

BACKGROUND & OBJECTIVES

Dental caries is an infectious microbial disease and mostly appears as a chronic disease. The rate of occlusal surface caries in children is 12.5% especially 90% seen in occlusal pit and fissures. Sealants forms a micromechanically bonded protective layer that prevents the invasion of caries producing bacteria, cuts off the access to nutrients. Many studies have evaluated the effectiveness of sealants in normal molars, very few studies have tested the retentiveness in the fluorosed molars.

Thus, study was designed to evaluate the retention and longevity of two non- fluoridated pit and fissure sealants HELIOSEAL and FISSURIT placed with and without use of bonding agents in young permanent molar affected by dental fluorosis at various intervals.

METHODS

After fulfillment of inclusion criteria, 45 Children were selected from the age group of 7-13 years of either gender and prior written informed consent were obtained. With split-mouth design, routine clinical procedure for fissure sealant application were followed with modification of increase in etching time to 35–40 sec for all the group. Helioseal sealant (Group IA & IB) was placed in the occlusal pits and fissures on the right side of all patients and Fissurit sealant (Group IIA & IIB) was placed on the left side. The sealants were randomly placed on the either sides.

Clinically retention rates were evaluated using the evaluation criteria given by Mascarenhas et al (2008) at recall intervals of 1 week and 1, 3, 6 and 12 months, tabulated and were subjected to statistical analysis with Mann–Whitney U test.

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Abstract

RESULTS

HELIOSEAL (Group-IB) without bonding agent showed the higher retention rate when compared to HELIOSEAL (Group-IA) with bonding agent, as well FISSURIT (Group-IIB) without bonding agent showed the higher retention rate when compared to FISSURIT (Group-IIA) with bonding agent revealed better retentiveness after 6 and 12 months was not statistically significant. But on comparing the retention rates of with and without bonding agent application of HELIOSEAL and FISSURIT, FISSURIT revealed better retentiveness after 3, 6 and 12 months which was not statistically significant.

INTERPRETATION & CONCLUSION:

Though not contraindicated, considering the extra time and cost needed and the inconclusive importance in retention, routine use of bonding agent as part of the sealant application technique is not recommended. Further studies with more sample size will be required to study the efficacy and retentiveness of these fissure sealants on fluorosed molars.

KEYWORDS

Pit and fissure sealants, Bonding agent, Fluorosed molars, Helioseal, Fissurit, Retention rate, Non-fluoridated Pit and fissure sealants.

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INTRODUCTION

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Introduction

1

INTRODUCTION

Dental caries is a multifactorial disease caused by alteration in the composition of the bacterial biofilm caused by acidogenic bacteria (Mutans Streptococci and Lactobacilli), salivary dysfunction, and dietary fermentable carbohydrates diffuses into the tooth and dissolves the mineral (demineralisation) leading to caries progression and regarded as a social disease in many countries, affects 100% of population in both primary and secondary dentition.^{1, 2}

Molars and premolars are the most vulnerable teeth to caries attack because is directly related to the morphology of their occlusal surfaces with narrow pits and fissures of about 0.1 mm width, with variable morphology (Y,IK,V,U,I). Unlike V and U shaped fissures which have a tendency to self-cleanse, I and IK shaped fissures have winding shapes with crevices and irregularities that acts as plaque retentive features in which food residues and bacteria become mechanically trapped and make them difficult to clean.³

Dental fluorosis has been defined as a specific disturbance in tooth formation caused by excessive intake of fluoride during the formative period of the dentition (Moller 1982). Dental fluorosis, an endemic dental disease prevailing in many countries around the world, has dramatically increased in frequency in several parts of India.

A study at the end of 1970s reported that, children aged 6-7 years had more than 50% of permanent molars affected by dental caries and as the age increases the percentage of molars affected by caries reached 80%. This indicates the importance of caries preventive strategies on occlusal surfaces. In children, caries begins shortly after the eruption of deciduous teeth and continue to increase at a significant rate during their school age.^4-5

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Introduction

2 Manton and Messer reported that pit and fissure caries represent a greater proportion of coronal lesions than interproximal lesions. Thus, there is a need to protect the occlusal surface of teeth from the caries process.⁶Ripa [1973] observed that occlusal surfaces accounted for almost 50% of the caries in school children despite the fact that they represents only 12.5% of the total surfaces of the permanent dentition.⁷

The term ‘pit and fissure sealant’ is used to describe a chemically-active liquid material that is introduced into the occlusal pits and fissures of caries-susceptible teeth, that after application, either cures chemically (auto-polymerizing),or is cured with a visible light source (light-cured), thus forming a micromechanically bonded protective layer that prevents the invasion of caries producing bacteria, and simultaneously cuts off the access of surviving caries-producing bacteria from their source of nutrients.⁸

The first clinical benefit from Buonocore’s workin 1955 was the introduction of the first dental pit and fissure sealant, Nuva-Seal, with ultraviolet light source. The focus of Buonocore’s early work was the development of a sealant to prevent occlusal caries on posterior teeth. Cueto and Buonocore in 1965 published the first paper on the pit and fissure sealant used 50% phosphoric acid buffered with 7% zinc oxide as the etchant as well as a mixture of methylmethacrylate monomer with the powder from the much-used silicate cements as the sealant.

One year later the authors have reported 87% caries reduction and 71%

complete retention of the sealant material. By the mid-1970s, many early clinical studies showed excellent retention and great promise in terms of potential caries prevention. Thus, in 1976, 3M Dental Products introduced the first colored sealant- Concise White Sealant, a chemically-cured material, white in color from the addition

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Introduction

3 of titanium dioxide, that is still in the market as of 2001. In 2001, both 3M (now 3M ESPE) and Ivoclar Vivadent introduced new sealants with color-changing capability.

By 1984, Cyril Burt reported that, There is general agreement that first and second molars should be sealed as soon as possible after eruption because of their susceptibility to occlusal caries.

Eccles, in 1989, noted that, Fissure sealants ought to be used preventively for the caries-prone patient, and therapeutically for the suspect or early carious lesion.

Clinicians seemed to be unsure whether to seal or not, whether to invasively prepare enamel or not prior to sealant application, and whether or not to resort to a preventive resin restoration. Burt has reported that, Changes in the distribution of caries in economically developed nations over the last 15-20 years include concentration of caries in pit and fissure lesions. In the Scandinavian countries the prime population strategies are the regular use of fluoride toothpaste and public education that emphasizes oral hygiene.⁹

At present, there are 2 main types of sealant materials available: resin-based sealants and glass ionomer cements. The resin-based sealants are divided into generations according to their mechanism for polymerization or their content. The development of sealants has progressed from first-generation sealants (no longer available) to second- and third generation sealants, which are auto polymerized and visible light activated, and finally to fourth-generation sealants containing fluoride.

The effectiveness of resin-based sealants has been shown, and the effectiveness depends on the longevity of sealant coverage. The second main type of sealant material is glass ionomer cements that were introduced in 1974. Glass ionomer (GI) cements are another type of sealant material that have been widely recognized and used for their fluoride-release properties, which stem from the acid-

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Introduction

4 base reaction between a fluoroaluminosilicate glass powder and an aqueous-based polyacrylic acid solution. Polyacid-modified resin sealants, also referred to as compomers, combine resin-based material found in traditional resin-based sealants with the fluoride-release and adhesive properties of GI sealants. Resin-modified GI sealants are essentially GI sealants with resin components that allow for light polymerization. Investigators have conducted a number of systematic reviews to determine the clinical effectiveness, cost effectiveness, and safety of pit and fissure sealants compared with another type of sealant material, a control without sealants, and fluoride varnishes. The main disadvantage of glass ionomer sealant has been inadequate retention.

Some evidence has also accumulated to indicate that RB sealants have higher retention rates than GIC sealants but was insufficient to determine whether fissure sealants or fluoride varnishes are the most effective measure for preventing caries, although there was some evidence that pit and fissure sealants are superior to fluoride varnishes for the prevention of occlusal caries.^10-11

There are multiple sealant materials, commercially available in market including resin-based sealants like urethane dimethacrylate or bisphenol A-glycidyl methacrylate monomers that are polymerized by either a chemical activation-initiation or a light activation system.¹¹

Successful applications of sealants rely upon smart clinical technique and the intact sealant protects the surfaces they cowl from decay. Complete isolation of the teeth from saliva contamination was reported as the principal criteria for the successful result of a sealant. Retention of sealant can be improved by enhancing the penetration of the sealant into the fissures. Because of their lower viscosity and higher

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Introduction

5 penetration rate, unfilled bonding agents has improved penetration into the fissures and more enamel tags than sealants resulting in their superior retention.¹²

Sealing of pit and fissures always brings the risk of contamination that influences an effective seal. Therefore, it is significant to highlight that, subsequent to correct indication for sealing, isolation of the tooth is the vital aspect of sealant placement [Locker et al., 2003]. Unfortunately, complete isolation of the tooth from contamination by saliva is very difficult considering the multisteps involved in the placement of pit and fissure sealants particularly in uncooperative children [Ashwin, 2007]. New alternatives are in market today in an attempt to achieve better results by simplifying the application steps. Among them, light-cured self-etching resins and glassionomer cements eliminate acid etch, rinse and dry steps which might require less chair-time.¹³

The use of the bonding agent could alter the rheology of the material allowing it to flow higher into the fissures and acid etched surface. The use of phosphate containing bonding agent could end in chemical bonding to the calcium of the enamel surface furthermore micromechanical retention from the sealant. Retention rates are of interest as sealant effectiveness is directly related to its retention and completely sealed fissures should not develop caries.¹⁴

Bonding agents have been introduced to enhance the seal at the tooth - restoration interface. Bonding agents are bi-functional molecules comprising of a methacrylate group forming a chemical bond to fissure sealant resin and a functional group with the ability to penetrate into the dentin or enamel surface.

The first clinical study in this respect was done by Boksman et al, who demonstrated that using bonding agent had no significant effect on increasing the retention of fissure sealant.¹⁵ Jaberi et al, in their study in 2008 on the effect of enamel

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Introduction

6 bonding on retention of fissure sealant revealed that under dry, isolated conditions, application of enamel bonding agent did not have a significant effect on retention of fissure sealant .¹⁶Sakkas C et al. in a clinical trial conducted in 2013 to evaluate the sealant retention rate and caries preventive efficacy of two fissure sealing techniques adhesive technique yielded better fissure sealing performance .¹⁷

To promote sealing capacity dentin bonding agent is applied, consisting of bifunctional molecules which includes a functional group that is able to penetrate wet dentin surface and a methacrylate group that bond to restorative resin by chemical interaction.¹⁸ Bonding to enamel occurs by micromechanical retention after acid etching is used to remove smear layer and preferentially dissolve hydroxyapatite crystals.¹⁹

Dental fluorosis, an endemic dental health problem in several countries around the world, has dramatically increased in frequency in several parts of India. Many studies have evaluated the effectiveness of sealants in normal molars, very few studies have tested the retentiveness in the fluorosed molars. Our college is in Namakkal District which is an endemically fluorosed area, thus decided to test the retention of the sealant in fluorosed molars and also to evaluate the application of bonding agent prior to the sealant application improved its retentiveness.

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AIM AND OBJECTIVES

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Aim and Objectives

7

AIM AND OBJECTIVES

Though many studies have been done to evaluate the effectiveness of sealants in normal molars, very few studies have tested the retentiveness in the fluorosed molars. Since our college is in Namakkal district which is an endemic fluorosed area, so we decided to test the retention of the sealant on fluorosed molars and also wanted to evaluate whether the application of bonding agent prior to sealant placement improved the retention. Henceforth, this study was carried out with the following aim and objectives.

Aim of the Study

To evaluate and compare the retention and longevity of two non-fluoridated pit and fissure sealants placed with and without use of bonding agents in young permanent molars affected by Dental Fluorosis in an interval of 1week, 1, 3, 6 and 12 months follow up.

Objectives of the Study

 To assess the retention and longevity of HELIOSEAL (Group-I) pit and fissure sealants with and without bonding agent in young permanent molar affected by dental fluorosis in an interval of 1 week, 1, 3, 6 and 12 months follow up.

 To assess the retention and longevity of FISSURIT (Group-II) pit and fissure sealants with and without bonding agent in young permanent molar affected by dental fluorosis at 1 week, 1, 3, 6 and 12 months follow up.

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Aim and Objectives

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 To assess and compare the retention and longevity between HELIOSEAL (Group-I) and FISSURIT (Group-II) pit and fissure sealants with bonding agent in young permanent molar affected by dental fluorosis in an interval of 1 week, 1, 3, 6 and 12 months follow up.

 To assess and compare the retention and longevity between HELIOSEAL (Group-I) and FISSURIT (Group-II) pit and fissure sealants without bonding agent in young permanent molar affected by dental fluorosis in an interval of 1 week, 1, 3, 6 and 12 months follow up.

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REVIEW OF LITERATURE

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Review of Literature

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REVIEW OF LITERATURE

Robert A et al. (1982) conducted a study to determine the combined retention rates of two Bis-GMA sealants ("Delton" and "Nuva-Seal”) in pedodontic clinic among 176 patients whose mean age was 11.5 years, retention rates have also been reported for all permanent teeth, in which maxillary were superior to the mandibular teeth with respect to sealant retention but the difference was not statistically significant and concluded that the high retention rates support the use of sealants as means of preventing pit and fissure caries in children.²⁰

Burt BA. (1984) did a study on the economics of sealant use and reported that there is a general agreement that the first and second molars should be sealed as soon as possible after eruption because of their susceptibility to occlusal caries.²¹

Opinya and Pameijer et al. (1986) conducted a study on the Tensile bond strength of fluorosed Kenyan teeth using the acid etch technique performed on 120 enamel specimens and observed that abrading the outer layer before etching resulted in higher tensile bond strengths, concluded that the increase in tensile bond strength indicates removal of the surface layer of fluorosed enamel by grinding then acid etching.²²

Redford DA et al. (1986) performed an in-vitro study to know the effect of different etching times on the sealant bond strength, etch depth, and pattern in primary teeth, evaluated the etching depth and bonding strength of 130 exfoliated primary teeth after the following four different etching times: 15, 30, 60, and 120 sec as greater increase in depth after 120 s etching time, the mean bond strengths obtained

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10 for the four etching times were not significantly different and concluded that it appear to be 60 second is adequate time for etching primary enamel.²³

Koch MJ et al.(1992) conducted a clinical evaluation of Helioseal F fissure sealant versus Delton opaque after 1 year of clinical testing, found Helioseal F has been evaluated in one lower molar as an unfilled control in lower molars. After 12 months there were no significant differences in retention, porosities, and the number of clinically unacceptable margins between the materials, results indicates that a sealant containing fluoride-releasing particles did not show a significant difference in retention rate compared to an unfilled conventional sealant.²⁴

Boksman L et al. (1993) conducted a study to evaluate whether the clinical effectiveness of pit and fissure sealant (Concise Light cured white sealant and Prisma shield light cured sealant) was increased when a bonding agent was used prior to the placement of the sealant and concluded that the use of a bonding agent prior to the application of a pit and fissure sealants does not increase the retention rate.¹⁵

Feigal RJ et al. (1993) did a randomized controlled trial compared fourth generation (three-step-etch-and-rinse) and fifth generation (two-step-etch-and-rinse) adhesives on sealant on salivary contaminated enamel, and found that the two-step adhesives reduced the risk of sealant loss by half when applied on occlusal surfaces.

On the other hand, the three-step adhesives had a detrimental effect on the sealant retention rate, which can be explained by the composition of the adhesive, as it is water-based, and water has a deleterious effect on sealant bonding. The two-step adhesive is acetone or ethanol-based, which may be more effective in bonding to etched enamel.²⁵

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11 Rajic Z et al. (2000) conducted a two year follow up study to know preventive sealing of dental fissures with Heliosil in primary and permanent teeth of 300 children with healthy parallel teeth of age 6–7 years and recommended that a procedure of sealing permanent first molars should be proclaimed as a precondition for enrolling in the first grade of primary school for all children in Croatia. The life of a sealant is 5 years, whereas the life of amalgam is 10 years, so 2 sealants cost less than 1 amalgam.²⁶

Yildiz E et al. (2004) conducted a study to compare the fluoride-containing fissure sealants (Helioseal F) with the conventional (Concise Light Cure White Sealant) fissure sealants in their retention and caries-prevention capabilities in young population. With recall appointments scheduled at 3, 6, 12 and 24 months after placement, full retention: 72.1% after 3 months, 46.7% after 24 months (nonsignificant), total loss of Helioseal F (16.4%, 19.7%, 18% and 23% at 3, 6, 12 and 24 months, respectively) was more than total loss of Concise Light Cure White Sealant (8.2%, 9.8%, 11.5% and 18%, respectively) nonsignificant difference between sealant materials for fully retained, partially lost and totally lost at any recall interval results of this study, the application of fissure sealants is highly effective in preventing caries in a young adult population, and the reduction of caries development is more related to the quality of sealant retention than to the content of the material.²⁷

Loyola-Rodriguez JB et al. (2005) conducted a study to compare the Conventional Sealant Technique (CST) and Enameloplasty Sealant Technique (EST) using a flowable resin as sealant in molars affected by dental fluorosis. A total of 40 extracted third molars affected by dental fluorosis were divided at random into two

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12 groups Tetric Flow resin was used as sealant. All teeth were studied for lateral adaptation and resin penetration by direct and indirect techniques; all samples were replicated in epoxy resin and were evaluated with Scanning Electron Microscopy (SEM) conclude that a flowable ceromer is an excellent material alternative to be used as sealant and that EST is quite necessary in molars affected by dental fluorosis, the combination of both being a reliable method to be used as primary prevention approach of dental caries in endemic areas of dental fluorosis.²⁸

Pinar A et al. (2005) conducted a study to assess the clinical performance of sealants with and without a bonding agent among 30 schoolchildren with all permanent first molars sound and unsealed of age: 8–10 years. Using Split-mouth design 4 molars from each child, with 1 maxillary and 1 mandibular molar from each child receiving sealant (Fissurit F, Voco/Cuxhaven) with a bonding agent. Marginal integrity and Retention rate at 12- and 24-month follow-ups were clinically acceptable.²⁹

Muller-Bolla et al. (2006) conducted a systematic review to evaluate the retention rate of the different materials of resin-based sealants (RBS) placed on permanent molars. There was no significant difference between the complete retention of light cured resin-based sealants (LRBS) and auto-polymerized resin- based sealants (ARBS). No statistically significant difference was observed when comparing LRBS with FRBS either at eight or 12 months. However, at the 48-month follow-up, the results indicated a significantly better retention for LRBS compared with Fluoride contained resin-based sealants (FRBS). The overall decrease in the complete retention rate was observed over time in all types of sealant materials.³⁰

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13 William et al. (2006) conducted a study to access that the microshear bond strength of resin composite bonded to hypomineralised enamel using 2 adhesive system3M ESPE Single Bond or Clearfil SE Bond investigate the adhesion of resin composite bonded to control and hypomineralized enamel with an all-etch single- bottle adhesive or self-etching primer adhesive. Specimens were stressed in shear at 1 mm/min to failure (microshear bond strength). Etched enamel surfaces and enamel- adhesive interfaces were examined under scanning electron microscopy was significantly lower than for control enamel. Since the intercrystal porosity and micro- tag formation were minimal after etching hypomineralised enamel, lower adhesion can be expected.³¹

Burbridge L et al. (2007) conducted a randomized controlled trial of the effectiveness of a one-step conditioning agent in fissure sealant placement 12-month follow-up reported a significantly better retention rate with the etch-and-rinse adhesive system (fifth generation) compared to the self-etch adhesive system (sixth - generation) at a 12 month follow-up and concluded that the best practice for placement of sealants remains enamel preparation with acid etch and use of an intermediate bonding layer.³²

Menon Preetha et al. (2007) conducted a study to examine the antibacterial properties of three commercially available sealants, viz, Teethmate-F, Helioseal-F and Helioseal. The testing was done with disc diffusion method and outcome of the result proved that Helioseal-F and Helioseal did not possess antibacterial properties and Teethmate-F was the only sealant that showed antibacterial properties.³³

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14 Azarpazhooh Amir, Main A Patricia (2008) conducted a systematic review on Pit and Fissure Sealants in the Prevention of Dental Caries in Children and Adolescents, recommended that the sealants should be placed on all permanent molar teeth without cavitation (i.e., permanent molar teeth that are free of caries, that have deep pit and fissure morphology, “sticky” fissures, or molar teeth with stained grooves) as soon after eruption as isolation can be achieved as well on the primary molars of children who are susceptible to caries (i.e., those with a history of caries) Sealants should be placed on first and second permanent molar teeth within 4 years after eruption.Sealants should not be placed on partially erupted teeth or teeth with cavitation or caries of the dentin. Resin-based sealants should be preferred, until such time as glass ionomer cements with better retention capacity are developed and placed as part of an overall prevention strategy based on assessment of caries risk.³⁴

Cehrelia ZC et al. (2008) conducted an in vitro study to evaluate the effect of long-term water storage on the microleakage of a fissure sealant applied with or without different bonding agents in 192 extracted human third molars were randomly assigned into 8 groups and concluded that the long-term water storage significantly increased the microleakage of Helioseal F applied alone and with a bonding agent.

Regardless of the storage medium, the use of etch-and-rinse adhesives resulted in significantly less micro leakage compared to that achieved with self-etching adhesives or acid etching alone. The sealants placed without a prior bonding agent showed the greatest amount of microleakage after 4 years.³⁵

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15 Jaber Ansari. Z et al. (2008) conducted a study to evaluate the efficacy of enamel bonding agent on pit and fissure sealant retention in a well-isolated situation among 32 patients and concluded that in a dry and isolated situation, application of enamel bonding agent has no significant effect on fissure sealant retention.¹⁶

Susan O. Griffin et al. (2009) examined the risk of caries development in teeth with partially or fully lost sealant (formerly sealed [FS] teeth) relative to the risk in teeth that never have received sealants (never-sealed [NS] teeth) and concluded that the teeth with fully or partially lost sealant were not at a higher risk of developing caries than were teeth that had never been sealed. ³⁶

Simonsen. R.J (2011) conducted a review of the clinical application and performance of pit and fissure sealants and recommended that the application of pit and fissure sealant to newly-erupted posterior (and occasionally, anterior) teeth is the best method in dentistry to prevent pit and fissure caries, and ⁄ or to prevent the continued development of incipient caries into frank caries when the incipient lesion is sealed over with resin.³⁷

Kühnisch. J et al. (2012) conducted a meta-analysis to assess longevity of materials for pit and fissure sealing and results revealed that the retention rate has become the true determinant and a valid surrogate endpoint for sealant effectiveness in preventing caries and also suggested that resin-based sealants can be recommended for clinical use. The faster and less error-prone clinical application of light polymerizing materials, however, makes them the preferred choice for daily dental practice rates.³⁸

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16 Nogourani M K et al. (2012) conducted a clinical study to investigate the effect of two adhesive systems Adper Single Bond, a two-step etch-and-rinse and Clearfil SE teeth compared the success of sealants in mesial and distopalatal grooves with and without these two adhesives systems and concluded that the use of bonding agent in pit and fissure sealants under both isolated and contaminated conditions.

Further, SE bond seemed to be less sensitive to moisture contamination.³⁹

Mickenautsch S Yengopal et al. (2013) appraised the clinical literature in determining whether loss of complete sealant retention as surrogate endpoint is directly associated with caries occurrence on sealed teeth as its clinical endpoint and to apply the appraised evidence in testing the null-hypothesis that the retention/caries ratio between different types of sealant materials (resin and glass-ionomer cement) risk of loss of complete retention of sealant materials was associated with the risk of caries occurrence for resin but not for GIC based sealants. The clinical evidence suggests that complete retention of pit and fissure sealants may not be a valid surrogate endpoint for caries prevention as its clinical endpoint.⁴⁰

Maher MM et al. (2013) conducted a study to clinically effectiveness of a self-etching adhesive on sealant retention in primary teeth. evaluated fissure sealants retention rate of in 90 primary molars using a sixth generation (one-step, two- component-self-etch) adhesive compared to the conventional phosphoric acid-etching technique with no bonding agent application. They found no statistically significant difference in retention of sealant using self-etching adhesives vs the conventional acid-etching technique in the two groups and concluded that replacing phosphoric acid-etching with self-etching adhesive Adper Prompt L-Pop does not compromise sealant retention in primary teeth after a 1-year period .⁴¹

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17 Mickenautsch S Yengopal (2013) conducted a systematic review on retention loss of resin based fissure sealants a valid predictor for caries manifestation purposed a null-hypothesis that retention loss of resin fissure sealants predicts caries manifestation no more accurately than random values was tested and predictions based on the retention loss of resin sealants, regarding caries manifestation, was no more accurate than random guesses. Sealant retention loss appears not to be a valid predictor for clinical outcome.⁴²

Muller-Bolla et al. (2013) conducted a split mouth randomized clinical trial was carried out to assess the Effectiveness of school based dental sealant programs among children from low-income backgrounds in France, concluded that the 1-year effectiveness of the school based dental sealant (SBDS) program was demonstrated in low socio-economic areas. Selection of schoolchildren according to individual caries risk factors should be considered in a SBDS program.⁴³

Sakkas C et al. (2013) conducted a clinical trial to evaluate the sealant retention rate and caries preventive efficacy of two fissure sealing techniques adhesive technique conventional acid-etch technique over a three-years, and concluded that the use of adhesive systems Optibond FL and Optibond Solo plus yielded better fissure sealing performance .¹⁶

Botsalı MS et al. (2015) conducted a study to examine the effect of bonding agents under fissure sealants on bond strength and microleakage of 210 freshly extracted non-carious human third molar teeth were used 105 teeth for shear bond strength and 105 teeth for microleakage assessment and concluded that Clearfil SE Bond improved the shear bond strength, and Adper Single Bond Plus decreased the

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18 microleakage of the fissure sealant. An inverse relationship was found between the microleakage and the shear bond strength performances of Adper Single Bond Plus.⁴⁴

Kobayashi et al. (2015) conducted a study to evaluate and compare for 24 months, the retention and surface characteristics of fluoride and non-fluoride resin- based pit-and-fissure sealants (Helioseal Clear and Helioseal F). The correlation between the different stages of eruption and sealant retention was also verified. And concluded Helioseal Clear sealant material exhibited the best performance regarding the retention and surface characteristics on the occlusal surface.⁴⁵

Mehrabkhani M et al. (2015) conducted a study to evaluate the effects of enamel or dentin bonding agent (DBA) and sealant viscosity on sealant microleakage among 60 extracted premolars and results indicated that the use of low viscosity sealant reduced the microleakage of pit and fissure sealants. However, the use of a bonding agent before sealant placement didn’t affect the microleakage.⁴⁶

Reddy V.R et al. (2015) conducted a clinical comparison to evaluate the retention of resin-based filled sealant Helioseal F and resin-based unfilled sealant Clinpro and concluded that the difference in retention rates between Helioseal F and Clinpro was not statistically significant, but Clinpro (unfilled) sealant showed slightly higher retention rates and clinically better performance than Helioseal F (filled).⁴⁷

Hasanuddin S et al. (2014) conducted a study to evaluate and compare the retention of fissure sealants and caries occurrence following the placement of Clinpro and FUJI VII fissure sealants by two different techniques simultaneously in young permanent molars affected by dental fluorosis. It was concluded that Clinpro fissure sealant showed a retention rate when compared with Fuji VII, regarding techniques, EST showed better results than CST in both the groups.⁴⁸

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19 Tandon V et al. (2015) conducted a study was to compare the effect of fifth and seventh generation bonding agent on sealant success in Sixty-four school children aged six to nine years received sealants in four permanent molars in a split mouth design, such that each patient received sealant in the first permanent molar with fifth generation bonding agent in one arch and seventh generation bonding agent in the other arch; contra-lateral molars were sealed with sealant alone. The evaluation was carried out at baseline, three months, six months and 12 months and concluded that a separate etch and rinse steps are not required for seventh generation bonding agents, and almost similar results were obtained for both sealant and seventh generation groups, it can be concluded that application of sealant along with a seventh-generation bonding agent may enhance sealant success and can be used for caries prevention in preventive programs.⁴⁹

Wright J T (2016) conducted a systematic review of randomized controlled trials on Sealants for preventing and arresting pit-and-fissure occlusal caries in primary and permanent molars.Available evidence suggests that sealants are effective and safe to prevent or arrest the progression of nonactivated carious lesions compared with a control without sealants or fluoride varnishes. Further research is needed to provide information about the relative merits of the different types of sealant materials.⁵⁰

Babaji et al. (2016) conducted an in vitro study to evaluate microleakage and shear bond strength of Tetric flow, Helioseal F, and enamel loc sealants in 36 extracted molars were randomly three different sealants, enamel surface was etched with 37.5% phosphoric acid for 60 s followed by washing and drying and concluded that Tetric flow recorded the highest shear bond strength and the difference was

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20 statistically significant with enamel loc. However, there was no statistically significant difference among the groups regarding microleakage.⁵¹

Ferrazzano GF et al. (2016) conducted an in vivo procedure for the standardised assessment of sealants retention over time. An experimental two-part system, consisting of a dental arch support and a camera support, concluded that Photographs, obtained through the experimental two-part system, allowing a reproducible positioning of the intraoral camera in oral cavity, could represent a standardised and useful method to monitor sealants retention over time.⁵²

Mohammed IP (2016) conducted a randomized control trial study to compare the effect of traditional acid etching (TAE) and of the self-etching (SE) agent in sealant retention among 6 to 13-year-old school children in Bengaluru city. The lower first molar were allotted with SE adhesive group or TAE group on lottery basis and concluded that SE adhesive used for sealing permanent molars of young children for a limited period, should be reviewed every 6 months.⁵³

Kumar G et al. (2016) conducted a randomised control clinical trial study to compare the retention rates of sealants placed with conventional acid etching or Er,Cr:YSGG laser pretreatment on enamel surface, in 200 permanent first molars in 6- 12 years old children in two groups of acid etching with 37% Phosphoric acidwas applied 15 Sec, rinsed with water for 20 Sec and air dried with air spray,and Er,Cr:YSGG laser the overall retention ratein acid etching was slightly higher as compared to Er,Cr:YSGG laser. Er,Cr:YSGG etching is comparable to acid etching in terms of retention and patient acceptability.⁵⁴

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21 Lele GS et al. (2016) conducted an in-vitro study to evaluate the self-adhering composite Dyad Flow as pit and fissure sealant with Fissurit F in 20 extracted premolars in two groups with a technique of enameloplasty after which the sealants were placed, they were thermocycled and subjected to 1% methylene blue dye penetration for 24 hours which were later sectioned mesiodistally and subjected to microleakage of the sealant and thus concluded that both Fissurit F and Dyad Flow performed similarly as pit and fissure sealants in term of microleakage.⁵⁵

Moreira KM et al. (2016) conducted a study were to assess long-term impact of tooth eruption stages (ES) on sealant retention on occlusal surfaces previously coated with intermediary bonding layer and to determine caries prevention and concluded that eruption stages affect sealant retention irregardless of the intermediate layer and type of sealant. However, there was caries prevention on tooth occlusal surfaces after 24 months regardless of treatment.⁵⁶

Mulder R et al. (2016) conducted an investigation was to establish whether Fissure Sealant (FS) remain a relevant preventive measure for the anatomically vulnerable fissure system. The group of teeth that had received FS protection demonstrated that Methylene Blue (MB) penetration into all the fissure system had been prevented. It became clear that fissure systems, although decalcified and even with an area of debris at the base of the narrow fissure, received adequate protection with FS application against the penetration of the MB solution during thermocycling.⁵⁷

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22 Nirwan M et al. (2017) evaluated the retention of pit and fissure sealant bonded using sixth (Adper promt), seventh (Optibond) and eighth (Futurabond Dual Cure) generations of adhesives and concluded that sealants effectiveness is directly related to its retention, and it depends on application procedures. The failure of retention of pit and fissure sealants can attribute to moisture contamination, improper curing methods, inadequate adhesion, improper application procedure, early age placement, varying behavior in children, and visually apparent variations in enamel.⁵⁸

Urvashi Bhushan et al. (2017) conducted a study to assess and compare the retention of pit and fissure sealants placed using acid etch alone and a combination of air abrasion and acid etch techniques on 50 subjects aged 6-8 years old including both primary second molar teeth and permanent first molar teeth, showed no significant difference in retention of sealants in Group A and Group B and six months follow up in primary and permanent molars significant showed superior retention compared to mandibular molars.⁵⁹

Panse et al. (2018) conducted an in-vitro study to comparison of microleakage, bond strength, and fracture strength of no etch no bond novel flowable composite as a pit and fissure sealant in comparison to the conventional sealants and concluded that the use of a flowable composite without bonding agent is a good alternative for sealing pits and fissures.⁶⁰

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MATERIALS & METHODS

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Materials and Methods

23

MATERIALS AND METHODS

The present study was conducted among children presenting to the Department of Pedodontics and Preventive Dentistry of Vivekananda dental college for women in Namakkal district. Ethical clearance for the study was obtained by local ethical committee (IEC/VDCW/48/2016). The Children were selected from the age group of 7-13 years of either gender. Written informed consent was procured from parents /guardians of all participants prior to the study.

Informed Consent Consideration

Each participant was presented with a letter detailing the purpose of the study, associated risks, and arrival. Children and parents/guardian (if interested) were allowed to review the room and the information. In the event if patient could not read, someone read the information out loud to the participants and their guardians. They were given an opportunity to ask questions and the researcher answered all questions prior to receiving final approval of participation in the study. Participants were not provided with any complements for the purpose of the study. The written permission was obtained from the Principal to conduct the study.

METHODOLOGY Study Sample

A clinical intervention was done among 7-13 years old children reporting to the Department of Pedodontics and Preventive Dentistry of Vivekananda dental college for women in Namakkal Dt., the study sample consists of 45 children.

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24 SAMPLE SIZE DETERMINATION

n= t² x p(1-p) m² Description:

 n = required sample size

 t = confidence level of 95% (standard value of 1.96)

 p = Expected Frequency of the Factor under Study – 2.6%

 M = margin of error of 5% (standard value of 0.05) Thus

n= 1.96² x 0.026(1-0.026) = 38 0.05²

Contingency

The sample is further increased by 5% to account for contingencies such as, non-response or recording error.

n +5 % = 38 + 5

Total sample size = 45 samples

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25 INCLUSION CRITERIA

• Children belonging to the age group of 7-13 years of either gender.

• Children affected with Dental fluorosis in grades 1-4 in accordance with Tooth Surface Index of Fluorosis (TSIF). ⁶¹

• Children free of Dental Caries.

• Fully erupted Young Permanent Molars with complete and intact tooth structure in all quadrants.

EXCLUSION CRITERIA

• Young Permanent Molars with Carious Occlusal Fissures.

• Molars unaffected by Dental Fluorosis.

• Molars with severe Fluorosis Attack (grade 5-7) according to TSIF.⁶¹

• Children affected with caries even in single Young Permanent Molars.

Collection of data

 A self-designed, proforma were made to collect data.

 The Dental caries Scores were recorded using Decayed Missing Filled Teeth index (DMFT/dmft).

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26 Armamentarium: (According to American Dental Association (ADA) standardization type 3 inspections).

Diagnostic Instruments:

 No.2 Mouth mirror

 No.23 explorer

 Tweezer

 Gloves

 Mouth masks

 Head Cap

 Disinfectants

 Sterile cotton

 Kidney Tray

 Green cloth

 Occlusal mirror

 Check Retractor Isolation System:

 Cotton rolls

 Rubber Dam Kit (GDC Fine Crafted Dental Pvt. Ltd.)

 Suction tips

 Pumice

 Polishing cup

 Contra-angle handpiece

 Tissue paper

 Applicator tip

 Light cure unit (SS WHITE ^®Dental Pvt. Ltd.)

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27

 Articulating Paper

 Cement dispensing tray

 Polishing kit (SHOFU Super-Snap- Rainbow Technique Kit)

 Camera (CANON-DSLR-D-1300)

Table 1 Sealant materials:

Material Composition Manufacture

SCOTCHBOND™

ETCHANT GEL, 3007

37% phosphoric acid 3M ESPE StPaul,MN,USA

ADPER SINGLE BOND 2

HEMA, Bis-GMA,Dim ethacrylate,

Vitrebond^TM Copolymer, Filler, Ethanol, water, Initiators

3M ESPE

Seefeld,Germany

HELIOSEAL

Mixture of Bis-GMA, dimethacrylate, titanium dioxide, initiators and Stabilizers

Ivoclar Vivadent AG, Schaan, Liechtenstein

FISSURIT

Bis-GMA, TEGDMA, UDMA, BHT,

benzotriazole derivative

Voco, Cuxhaven, Germany

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28 Fig:1 Armamentarium for Group IA

Fig:2 Armamentarium for Group IB

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29 Fig:3 Armamentarium for Group IIA

Fig:4 Armamentarium for Group IIB

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30 Fig:5 Armamentarium for Isolation

Fig:6 Armamentarium for Polishing

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31 Fig:7 Armamentarium for Review

STUDY DESIGN

Children with mild to moderate Dental Fluorosis were randomly divided into 2 Groups I, II based on the type of sealant used. Groups were further divided into Sub- Groups: Sub-Group A-with bonding agent, Sub-Group B-without bonding agent.

Sealant Application Design

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32 PROCEDURE

This study had a split-mouth design in which the young permanent molars of the same side received one sealant material type and the contralateral first molars received the other sealant material type. First, the mouth side (right or left) and then the material type was chosen using the Excel program from Windows. The other sealant applications followed this initial choice. Previous to sealant application, the stage of eruption of the selected teeth were evaluated and the children affected with Dental fluorosis in grades 1-4 in accordance with Tooth Surface Index of Fluorosis (TSIF)⁶¹ were included.

Routine clinical procedure for fissure sealant application was followed. The only modification in the clinical technique was that an increase in etching time to 35- 40 seconds for all the groups⁴⁹. In all the participants, isolation of teeth has been achieved by using cotton rolls , disposable suction tips and rubber dam isolation.

Helioseal sealant (Group IA & IB) was placed in the occlusal pits and fissures on the right side of all patients and Fissurit sealant (Group IIA &IIB) was placed on the left side. The sealants were randomly placed on the either sides.

Each tooth was isolated with heavy-gauge rubber dam and then given a pumice prophylaxis. Each tooth was acid etched with 37% phosphoric acid gel for 45 seconds, followed by a 30 seconds water lavage. After air drying with chip blower, sealant was placed with a fine sable-hair brush, teased into the crevices with an ADA Specification No.23 explorer and cured for 20 seconds according to the manufacturer instructions. For each tooth on the left side, the, same sequence was used, except that the appropriate bonding agent was placed with a sable-hair brush and thinned with a

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33 gentle stream of air with chip blower before the placement of sealant and 20 seconds cure. Children were instructed not to eat for at least 1 hour after the procedure⁴⁹. All the children received instructions on good oral health practices and brushing methods.

The sample of 45 patients were distributed as per category. All the sealed teeth were evaluated and scored for retention by means of a mouth mirror and explorer at 1 week, 1, 3, 6 and 12 months interval using Mascarenhas et al. (2008)⁶² scoring criteria by another examiner, a senior faculty member.

Fig:8 Pre-OP Photographs of Maxillary and Mandibular Arch.

Fig:9 Post-OP Photographs of Maxillary and Mandibular Arch.

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34 Table:2 Mascarenhas et al. criteria (2008).⁶²

Score Criteria

Score 1 Sealant completely covering occlusal surface and all buccal pits and palatal fissures

Score 2a Sealant partly covering the tooth and the tooth is sound Score 2b Sealant partly covering the tooth and the tooth is carious Score 3a Sealant completely lost and the tooth is sound

Score 3b Sealant completely lost and the tooth is carious

Fig:10. Application of sealants.

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35

Fig:11 Acid Etching.

Fig:12 Application of Bonding Agent

Fig:13 Light curing of Bonding agent.

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36 Fig:14 Application of sealants

Fig:15 Application of sealants Group I &Group II

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37 Fig:16 Evaluation of sealants during intervals.

Fig:17 Evaluation of sealants Score 1.

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38 Fig:18 Evaluation of sealants Score 2.

Fig:19 Evaluation of sealants Score 3.

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39 Fig:20 Evaluation of sealants during intervals.

Fig:21 Evaluation of sealants at 1 week interval.

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40 Fig:22 Evaluation of sealants at 1 month interval.

Fig:23 Evaluation of sealants at 3 month interval.

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41 Fig:24 Evaluation of sealants at 6 month interval.

Fig:25 Evaluation of sealants at 12 month interval.

A visual inspection was performed to evaluate the presence of any incipient carious lesions on the occlusal surfaces of the sealed molars at all recall intervals. The results were tabulated and were subjected to statistical analysis.

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RESULTS

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Results

42

RESULTS

Table: 3 Retention rates among Group I (HELIOSEAL) and Group II (FISSURIT) fissure sealant materials at 1 week, 1, 3, 6 and 12 months.

Duration Retention

Group I (HELIOSEAL)

Group II (FISSURIT)

N % N %

1 Week

Total Retention 90 100 90 100

Partial Retention 0 0 0 0

Total Loss 0 0 0 0

Total 90 100 90 100

1 Month

Total Retention 90 100 90 100

Partial Retention 0 0 0 0

Total 90 100 90 100

3 Months

Total Retention 80 88.9 76 84.4

Partial Retention 10 11.1 14 15.6

Total 90 100 90 100

6 Months

Total Loss 2 2.2 2 2.2

Total 90 100 90 100

12 Months

Total Loss 19 21.1 23 25.6

Total 90 100 90 100