Pit and Fissure Sealant Materials

3.1. Resin-Based Sealant Materials (RBSs) 

Resin-based sealants (RBS) are classified into four generations, determined by the method of
polymerization. The first generation of RBS was polymerized by the action of ultraviolet rays
on the initiators in the material that initiate polymerization; this type, however, is no longer
used [20]. Nuva-Seal® (LD. Caulk Co.: Milford, DE, USA) was the sealant first introduced to
the market and is an example of a resin-based sealant polymerized by an ultraviolet light
source. The second generation was the auto-polymerizing resin-based sealants (ARBS) or
chemically-cured sealants; tertiary amine (the activator) is added to one component and
mixed with another component. The reaction between these two components produces free
radicals that initiate the polymerization of the resin sealant material [20]. Such
autopolymerizing resin-based sealants have now largely been replaced by the third
generation, which comprises visible light-polymerizing resin-based sealants (LRBS). In this
type of sealant, the visible light activates photoinitiators that are present in the sealant
material and are sensitive to visible light in the wavelength region of around 470 nm (blue
region) [21]. On comparing this visible light polymerizing to its previous generation, the
autopolymerizing resin-based sealant, LRBS, sets in a shorter time, namely, 10–20 s,
compared to the 1 to 2 min setting time of ARBS. The working time is longer and the
material does not set until exposure to the polymerizing light. Through the elimination of the
mixing step, fewer air bubbles are incorporated with the sealant application [22]. The fourth
generation is the fluoride-releasing resin-based sealants (FRBS). Fluoride resin-based sealant
is the product resulting from adding fluoride-releasing particles to LRBS in an attempt to
inhibit caries. According to the literature, however, FRBS cannot be considered as a fluoride
reservoir providing a long-term release of fluoride, and, as such, this kind of sealant provides
no additional clinical benefit to LRBS [23,24,25]. 
RBS can also be classified according to their viscosity (filled and unfilled). The addition of
filler particles to fissure sealant material seems to have only a small effect on clinical
outcomes. Although filled sealants have a higher wear resistance, their ability to penetrate
into fissures is low. The filled sealants usually require occlusal adjustments, which lengthen
the procedure unnecessarily. The unfilled resin sealants on the other hand have a lower
viscosity and provide greater penetration into fissures and better retention [23,26]. 
Sealant materials can also be classified according to their translucency (opaque and
transparent) [23]. Opaque material can be white or tooth-colored, and transparent sealants can
be clear, pink, or amber. White opaque fissure sealantsare easier to see during application and
to detect clinically at recall examinations, compared to tooth-colored, opaque, or clear
sealants [20]. A study has shown that the identification error was only 1% for the opaque
resin sealant, compared to 23% for clear resin sealant [27]. However, the choice of the sealant
material is usually a matter of personal preference.
Advances in the technology of resin sealant materials include the incorporation of a color
change property. The change of this color property is either in the curing phase, such as
Clinpro (3M ESPE, Saint Paul, MN, USA), or in the phase after polymerization, such as
Helioseal Clear (Ivoclar Vivadent, Schaan, Liechtenstein). The advantage of this technology
has not yet been fully proven but it may indeed offer the advantage of the better recognition
of sealed surfaces [20,23]. It therefore seems that the most suitable choice of resin-based
sealant would be the light polymerizing, unfilled, opaque sealant.
3.2. Glass Ionomer Sealant Materials 
Conventional glass ionomer (GI) material has also been used as pit and fissure sealants. It
bonds chemically to enamel and dentin through an acid-base reaction between an aqueous-
based polyacrylic acid solution and fluoroaluminosilicate glass powder [28]. GI sealants can
be classified into low viscosity and high viscosity types. It is important to recognize that most
of the studies on GI sealants used old-generation, low-viscosity GI, such as Fuji III GI sealant
that has poor physical properties. It has now been replaced with a later generation, such as
Fuji Triage (VII) (GC, Tokyo, Japan), that has better physical properties and is designed to
release a higher amount of fluoride [29]. High viscosity glass ionomer cement (HVGIC),
such as Ketac Molar Easymix (3M ESPE, Seefeld, Germany) and Fuji IX (GC, Tokyo,
Japan), has been used in studies following atraumatic restorative treatment approach (ART).
The ART concept consists of two components, namely, ART sealant and ART restoration.
ART sealant is the preventive component that includes the application of HVGIC on
vulnerable pits and fissures using the finger-press technique [30].
When resin is incorporated with glass ionomer, it is called a resin-modified glass ionomer
(RMGI). It has also been used as a pit and fissure sealant material. The setting reaction of this
type of sealant is initiated by the photoactivation of the resin component, followed by the
acid-based reaction for the ionomer component. Its resin component has improved its
physical characteristics, compared to conventional GI [22]. In fact, when compared to
conventional GI, RMGI has less sensitivity to water and a longer working-time [28]. 
In general, the main advantage of a glass ionomer cement-based sealant is the continuous
fluoride release and the fluoride recharging ability. Its preventive effect may even last after
the visible loss of the sealant material as some parts of the sealant may remain deep in the
fissures. It is moisture-friendly and easier to place and is not vulnerable to moisture,
compared to the hydrophobic resin-based sealants [22]. It can be used as a transitional sealant
when resin-based sealants cannot be used due to difficult moisture control in, for example,
partially erupted permanent teeth, especially when the operculum is covering the distal part of
the occlusal surface [31]. GI sealant can also be useful in deeply fissured, primary molars that
are difficult to isolate due to a child’s pre-cooperative behavior [20]. It is considered a
provisional sealant and has to be replaced with a resin-based sealant when better isolation is
possible [32].

3.3. Polyacid-Modified Resin Based Sealants

Polyacid-modified, resin-based composite material, which is also referred to as compomer,
has been used as a fissure sealant. It combines the advantageous properties of a visible light
polymerized resin-based sealant with the fluoride releasing property of the GI sealant. A
polyacid-modified resin-based sealant has a better adhesion property to enamel and dentin
and is also less water-soluble, compared to GI sealant material [33], and less technique-
sensitive, compared to resin-based sealants.

5. Sealant Retention of Different Materials

Previously, when investigating the effectiveness of sealants in preventing caries, half-mouth
study designs were used, in which sealed teeth were compared with unsealed teeth as
controls. Once the protective role of pit and fissure sealants was established in the 1980s, this
type of study design became unethical. In other words, it was no longer acceptable to leave
teeth with no sealant as a control after the efficiency of sealant in preventing caries had been
proven. Since then, the retention rate has become the true determinant and a valid surrogate
endpoint for sealant effectiveness in preventing caries [24,46]. The retention rate in most
studies is classified into “intact sealant”, “partial loss”, and “complete loss” [47]. However,
Mickenautsch and Yengopal in their recent systematic review do not support the use of
sealant retention as a valid predictor for caries manifestation [48,49].
A systematic review evaluated the retention rate of the different materials of resin-based
sealants (RBSs) placed on permanent molars. There was no significant difference between
the complete retention of LRBS and 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 FRBS. The overall decrease in the complete retention rate was observed over time in all
types of sealant materials [24].
A recent meta-analysis investigated the clinical retention rates of pit and fissure sealants with
regard to different types of materials at different observation-times. The resin-based sealants
showed the best retention rates: the five-year retention rates for light-polymerizing,
autopolymerizing, and fluoride-releasing resin-based sealants were 83.8%, 64.7%, and
69.9%, respectively. The GI-based fissure sealants, on the other hand, had a 5.2% retention
rate at the five-year observation-time. Polyacid modified resin sealants also showed low
retention rates [46]. However, studies that used HVGIC [50,51] or Fuji Triage [52] have
shown improved retention rate results for GI sealants that are comparable to resin-based
sealants.
When comparing filled and unfilled resin-based sealant retention rates, a study evaluated the
retention of resin-based filled sealant Helioseal F (Ivoclar Vivadent, Schaan, Liechtenstein)
and resin-based unfilled sealant Clinpro (3M ESPE, Saint Paul, MN, USA). They concluded
that unfilled resin-based sealants showed slightly higher retention rates at the 12-month
follow-up compared to those for filled resin-based sealants. Complete retention was 53.57%
for filled RBS and 64.39% for unfilled RBS, but the difference was not statistically
significant. Sealants without fillers appear to have better penetration into fissures than
sealants incorporating filler particles, due to their lower viscosity [26].
The recent update of the American Dental Association’s recommendations, in collaboration
with the American Academy of Pediatric Dentistry, reported that the GI sealant retention loss
is five times greater compared to RBS and three times greater compared to RMGI sealant.
The difference here is statistically significant, but the quality of evidence was assessed as
being very low (Table 2) [5,28].
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6. Techniques for the Placement of Resin-Based Sealants 

6.1. Tooth-Cleaning, Enamel Preparation, and Tooth Surface Treatment Prior to

Sealant Placement
Most of the manufacturers’ instructions for the use of fissure sealants recommend careful
cleaning of the pits and fissures before acid etching. A study reported that there is in fact no
difference in sealant retention between toothbrush and handpiece prophylaxis at two to five
year follow-ups [53]. 
Some manufacturers’ instructions state that the use of fluoride before sealant placement is
contraindicated as it decreases enamel solubility in acid and thus inhibits proper etching of
the enamel. However, Warren et al. compared the sealant retention of two sealant materials
before and after fluoride treatment over an 18-month period. They reported a significantly
greater retention on fluoridated teeth when LRBS was used and no significant difference in
retention when ARBS was used. This suggested that sealant retention may not be impaired by
fluoride application immediately prior to sealant placement [54]. Similarly, another study
reported that the use of fluoride-containing prophylaxis paste or any fluoride treatment before
sealant application does not adversely affect the sealant’s bonding to enamel [55]. One more
study also evaluated sealant retention when treating the enamel with a topical fluoride gel
before acid etching clinically and in-vitro. It was found that there was no statistically
significant difference between the retention rate of the sealant applied after tooth surface
treatment with topical fluoride and the control group that did not receive any fluoride
treatment prior to the sealant application [56]. Furthermore, many studies have investigated
different methods of mechanical preparation of the fissures, such as air abrasion, eliminating
fissures with a dental bur, and sandblasting, prior to the sealant placement . Interestingly, it
was found that fissure eradication is not necessary. Enameloplasty, using any of the above-
mentioned techniques, removes the enamel layer overlying the dentin at the bottom of the
fissure, making the tooth more susceptible to caries if the sealant is lost [20,57]. There is
conflicting and limited evidence regarding the benefits of using a bur for fissure cleaning or
for the purpose of increasing retention, prior to sealant placement [32,58].

6.2. Isolation
Adequate moisture isolation during resin sealant placement is the most critical step in sealant
application. If the etched enamel gets exposed to salivary proteins for as little as 0.5 s, it can
be contaminated [36]. If this occurs, re-etching is required. The use of a rubber dam is the
ideal way to achieve optimum moisture control. The use of cotton rolls and a saliva ejector is
also a valid option [59]. The use of moisture control systems, such as the Isolite® system
(Innerlite Incorporation, Santa Barbara, CA, USA) provides less time for the procedure and
offers comparable sealant retention rates to cotton roll isolation or the use of a rubber dam
[60].
A systematic review has suggested that four-handed delivery, compared to two-handed
delivery, increases sealant retention by 9% when other factors, such as the surface cleaning
method, were controlled [61]. The use of the four-handed technique facilitates sealant
placement and is also associated with improved retention [32]. 

6.3. Acid Etching and Rinsing

The phosphoric acid concentration that was originally used for etching by Buonocore in 1955
was 85%, but it was then reduced in his early clinical studies to 50% [18]. Nowadays, 35%
and 37% are the commonly used concentrations. Acid-etching times have also been reduced
from 60 s down to 20 s [62].
Early recommendations for primary teeth enamel etching time were double the accepted time
for permanent enamel, namely, 120 s for primary enamel and 60 s for permanent enamel. The
early in vitro studies showed that 120 s are necessary for an adequate etching pattern in
primary teeth enamel to eliminate the identification of prismless enamel. This finding was
found not to be clinically significant for sealant retention, as demonstrated by Simonsen et al.
in 1978. His study included 56 children between the ages of 3–8 years with 373 deciduous
first and second molars that were sealed and examined six months post-application; 178 teeth
were etched for 60 s and 195 teeth were etched for 120 s. The retention rate for the 60 s
etched teeth was 100%, and for the 120 s etched teeth, it was 99% [8,23]. Moreover, the
shorter etching time decreases the chance of saliva contamination, particularly in pre-
cooperative children.
An in-vitro study evaluated the etching depth and bonding strength of 130 exfoliated primary
teeth after the following four different etching times: 15, 30, 60, and 120 s. Despite the
greater increase in depth after 120 s etching time, the mean bond strengths obtained for the
four etching times were not significantly different [63]. Another study showed that the length
of etching time has little effect on sealant retention. No significant difference in fissure
sealants’ retention on primary or permanent molars was found after a one-year follow-up
with different etching times of 15, 30, 45, and 60 s [64]. 
A rinsing time of 30 s and drying the tooth for 15 s should be sufficient to remove all acid
etchant residues and achieve the characteristic chalky white enamel frosty appearance
[20,22].

6.4. Bonding Agents

The idea of using a bonding agent under the sealant came from Feigal et al. in 1993 when
they used hydrophilic bonding materials to aid the bond strength when the sealant is applied
in a moist environment [65]. 
There have already been eight generations of bonding agents [66,67,68], the latest and eighth
one being introduced in 2010. It is characterized by the incorporation of nano-fillers into the
adhesive composition to improve the mechanical properties of the adhesive system. However,
the most recent type in adhesive dentistry is called the universal adhesive or the multi-mode
adhesive. It was first introduced in 2011. This kind of adhesive system can be used as an etch
and rinse adhesive, a self-etch adhesive or to do self-etch on dentin and etch-and-rinse on
enamel; this particular technique is called selective enamel etching. Its composition differs
from the other adhesive systems that allow chemical and micromechanical bonding [67]. All
the various adhesive types are summarized in Table 3. Several studies evaluated the use of a
bonding agent before sealant application. A randomized controlled trial compared fourth
generation (three-step-etch-and-rinse) and fifth generation (two-step-etch-and-rinse)
adhesives when used under sealants. They found that the two-step adhesives reduced the risk
of sealant loss by half (Hazard ratio = 0.53) 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 [69].
With regard to self-etch adhesives, a recent clinical trial evaluated the sealant retention rate
and caries preventive efficacy over a three-year period. They compared three adhesive
generations, namely, fourth generation (three-step-etch-and-rinse), fifth generation (two-step-
etch-and-rinse), and sixth generation (one-step, two-component-self-etch) with the
conventional technique, which is etching with no adhesive application as a control. There was
a significant difference between the retention rates of sealants combined with the various
adhesive systems used (p < 0.05). The highest retention rates of sealants on the first
permanent molars at a 36-month recall were combined with the fourth and fifth generation
adhesive systems and were 80.01% and 74.27%, respectively. In contrast, the lowest
retention rates were combined with the sixth generation adhesive system (42.84%) and with
the conventional acid-etch technique (62.86%). They also found that the fissure caries
incidence rate in first permanent molars that had been sealed after using the sixth generation
adhesive system was 34.28%, which was significantly higher than when other adhesive
systems had been used [70]. This was in agreement with a previously published study that
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 [71]. Another study, on the other hand, evaluated the retention rate of fissure
sealants in 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 sealant retention in the
two groups after a one-year follow-up period [72].
A recent systematic review compared the retention rate of sealants, combined with self-etch
adhesive systems(sixth or seventh generation), with that of etch-and-rinse adhesive systems
(fourth and fifth generations). Five studies were involved: three studies showed that etch-and-
rinse adhesive systems had significantly better retention than self-etch adhesive systems. The
other two included studies showed no significant difference between the two adhesive
systems. Feigal and Quelhas in 2003, for example, reported similar retention rates of 61% at
24 months. However, the sample in this study was small (18 molars only) [73]. The
systematic review concluded that the retention of occlusal fissure sealants is higher when
applied with the etch-and-rinse adhesive system than with the self-etch adhesive system [74]. 
Finally, a recent systematic review by Bagherian et al. evaluated the fissure sealant retention
rate with or without the use of an adhesive system and also compared the retention rate of
sealants when using etch-and-rinse adhesive systems (fourth or fifth generations) versus the
rate achieved when self-etching adhesive systems (sixth or seventh generations) were used.
They found that the adhesive system has a positive effect on the retention of the fissure
sealant. The adhesive components may increase the penetration into enamel porosities and
thus increase bond strength. It was also found that etch-and-rinse adhesive systems are
superior to self-etch adhesive systems in terms of sealant retention [75]. However, in a recent,
randomized controlled trial, Khare et al. evaluated the integrity of fissure sealants by
comparing the use of fifth, seventh, or Universal bonding systems with a no bonding protocol
at 3-, 6- and 12-month follow-ups. At the 12-month follow-up, fifth generation bonding and
universal bonding protocols performed better than seventh generation or no-bonding
protocols, but the difference between the groups was not statistically significant [76].
In summary, the above-mentioned studies indicated that the use of adhesive systems prior to
fissure sealant application had a positive effect on increasing penetration and improving the
retention rate. It also appears that the use of bonding-agents that involve a separate acid-
etching step (fourth and fifth generations) provides better sealant retention than self-etching
adhesives (sixth and seventh generations). Etch- and-rinse adhesive systems produce better
penetration of the enamel surface than self-etch adhesive systems, and this may result in a
better bond strength.
An evidence-based 2008 report from the American Dental Association and the American
Academy of Pediatric Dentistry supports the use of adhesive systems before sealant
application for better sealant retention [32,58]. 

6.5. Sealant Evaluation After Placement

After curing the sealant and before the removal of the isolation material, the operator should
examine the sealant for any voids, bubbles, or deficient material. Sealant retention should
also be checked using the explorer in attempt to remove the sealant. If the sealant is
dislodged, the fissures should be re-checked for any remaining food debris that may have
caused the debonding of the sealant material. The tooth should be re-etched and a new sealant
material should be applied. The operator should also be cautious enough to remove excess
sealant material over the distal margin that may create a ledge [44].

7. Sealing Primary Teeth 

On the basis of caries risk assessment, primary teeth can be judged to be at risk due to fissure
anatomy or patient caries risk factors, and would therefore benefit from sealant application
[55]. Therefore, pit and fissure sealants are indicated in primary teeth, if such teeth have deep
retentive or stained pits and fissures with signs of decalcification or if the child has caries or
restorations in the contralateral primary molar or any other primary teeth [44]. Sealing should
be considered particularly for children and young people with medical, physical, or
intellectual impairment [59].
Pit-and-fissure sealants were found to be retained on primary molars at a rate of 74 to 96.3%
at one year and 70.6–76.5% at 2.8 years [58]. However, the focus of most sealant studies is
the occlusal surfaces of permanent molars and there is still insufficient evidence to support
the use of fissure sealants in primary molars [32]. Rathnam and Madan maintain that it is
difficult to conduct clinical studies on primary teeth due to several confounding factors, such
as age, cooperation, and the behavior of the child when presented within an unfamiliar set-up,
such as in the dental clinic [77]. To simplify the clinical procedure and make fissure sealant
application more acceptable to young children, a shorter etching time may be used to
decrease the chance of saliva contamination. As mentioned earlier, several studies showed
that the length of etching time has a minimal effect on sealant retention [64]. Another
measure that can be used with young children in an attempt to shorten the procedure time is
to use self-etching bonding agents as an alternative to the conventional acid etching
technique. Several studies have shown an insignificantly lower sealant retention rate in
primary teeth when self-etching bonding agents have been used, compared to conventional
acid etching [72,78]. Moreover, studies have shown that using a GI sealant may be a good
interim option when salivary contamination is expected because it has a higher toleration to
moisture compared to resin-based sealants [31]. However, studies on the use of GI sealants in
primary teeth are very limited [79] and considerably more research is therefore needed in this
area [42].
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8. Cost-Effectiveness of Dental Sealants 

A cost-effectiveness analysis can be used to analyze the cost in relation to the outcome. In the
case of sealants, we must ask how many carious lesions are prevented when dental sealants
are applied [80]. Dental sealants do seem to be a cost-effective intervention; sealing
permanent molars reduces the total cost by preventing the need for more expensive and
invasive restorative treatment. Sealants are considered to be more cost-effective if they are
used with children at a high risk of caries and with teeth surfaces susceptible to caries. It is
therefore recommended that sealants should be used selectively, based on the child’s caries
risk and the anatomy of the fissures [5,32,81,82]. Developing methods for targeting children
at a high caries risk is therefore important to ensure the cost-effective use of sealants [82].
Perception of the susceptibility of pits and fissures to caries varies from practitioner to
practitioner, when simple terms such as “deep occlusal anatomy”are used. Practitioners
should be aware of the teeth and teeth surfaces that are most susceptible to caries and include
them in treatment planning for sealants. For example, deep, narrow, I-shaped fissures are
relatively more caries-susceptible, compared to shallow, wide, V-shaped fissures [22]. Newly
erupted permanent first molars should also be seen as susceptible teeth, prior to full eruption.
Dentists should think about how to protect such teeth from getting carious and whether to
seal at an early or late stage of eruption. Buccal pits and lingual grooves are also considered
caries-susceptible areas that are difficult to seal [83]. Sealant application is part of caries
management protocol for high caries risk patients [84]. It is therefore important to evaluate to
what extent other preventive approaches are used, such as professional topical fluoride
application, regular daily toothbrushing with fluoridated toothpaste, the use of fluoride
supplements, and diet counseling [59,84]. Caries risk is assessed using indicators such as low
socio-economic status, previous caries experience, sugar consumption between meals, the
presence of active white spot lesions, and low salivary flow [84].
A study showed that risk-based sealing improves clinical outcomes and saves money over
never sealing. It should also be mentioned that sealing permanent molars in all patients
further improves the outcome, adding only a small incremental cost relative to risk-based
sealing [85]. A recent Cochrane review concluded that sealants have proved to be effective in
preventing caries in high caries risk children [35]. Another study concluded that sealing
primary molars reduces restorations and extractions, but is more expensive than not sealing
[81]. It is therefore recommended that, to be more cost-effective, sealants be used only in
children at a caries risk of develping caries [32].

9. Sealing Non-Cavitated Carious Lesions

Non-cavitated carious lesions refer to initial caries lesion development without any
cavitation. They are defined by a change in color, surface structure, and glossiness due to
demineralization before macroscopic breakdown occurs. Re-establishing the balance between
remineralization and demineralization may stop the progress of caries leaving a clear clinical
sign of past disease [1]. 
Due to the difficulty in diagnosing non-cavitated occlusal caries, dentists may have been
inadvertently sealing caries over the years [36]. Many studies suggest that caries progression
is slowed or arrested under sealants [86]. Blocking the bacterial nutritional supply may be the
explanation for the arrest of caries progression observed under sealants [87]. A meta-analysis
examined the caries progression under sealed permanent teeth. Six studies were included in
the analysis, representing 840 teeth. Four of them sealed non-cavitated lesions and the other
two used sealant over restorations. The median annual percentage of progression of non-
cavitated caries lesions was 2.6% for sealed teeth and 12.6% for not-sealed teeth. This
suggests that sealing non-cavitated lesions is effective in reducing progression [86]. Another
randomized, controlled trial evaluated the progression of non-cavitated dentinal lesions under
sealants. They included 30 molars in the sealant group (experimental group) and 30 molars in
the no-sealant group (control group). The results showed a remarkable difference between the
two groups; at the eight month-recall, 25 out of 26 molars (96.1%) in the control group
showed caries progression. At the 12-month-recall, three out of 26 molars (11.5%) in the
experimental group were present with caries progression. These molars were observed to
have partial or complete sealant loss. The partial and total loss of sealant thus limited the
effectiveness in arresting caries lesions [88]. Moreover, a recent critical appraisal provided
evidence from clinical trials about sealing incipient occlusal caries lesions and concluded that
caries lesions do not progress under well-sealed surfaces. However, the clinical success of
sealing non-cavitated lesions is dependent on the complete retention of the sealants [89]. 
Sealing non-cavitated carious lesions seems to also have an effect on bacterial count. A
systematic review that included six studies reported that sealing was associated with at least a
10-fold decrease in bacterial counts. About 47% percent of sealed teeth had viable bacteria,
compared to 89% of unsealed lesions. They concluded that sealants were effective in
reducing bacterial counts in carious lesions, but a limited number of organisms neverthless
persisted [87]. Another recent systematic review supported sealing non-cavitated dentinal
lesions and concluded that resin-based sealants are able to arrest the caries progression of
non-cavitated dentinal lesions, while GI sealants showed low retention rates and are not able
to arrest caries progression [90].
Dentists, on the other hand, have not yet adopted these findings in their clinical decision-
making. A questionnaire was mailed to a randomly selected sample of 2400 dentists, of
whom 771 responded. When there was no radiographic evidence of caries extending to
dentin, only 38.2% of the dentists claimed that they would seal the tooth’s occlusal surface,
and 23% chose the option of opening the fissure [91]. 
The available evidence and the recommendations from the ADA Council, as well as the
AAPD guidelines, support sealing occlusal non-cavitated early carious lesions in children and
young adults. However, sealants are most effective if they are regularly monitored and
repaired [28,32,58].
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10. Follow-Up (Recall-and-Repair)

The average sealant loss from permanent molars is between five to ten percent per year [83].
Regular sealant maintenance is therefore essential to maximize efficiency, maintain marginal
integrity, and provide the protection given by optimal sealant coverage [32,92]. A study
evaluated more than 8000 sealants over a period of ten years; its authors reported a sealant
success rate of 85 percent after eight to ten years, due to the incorporation of an annual recall
and repair program. Complete sealant retention without any need for resealing was 41 percent
at ten years [93]. In another study where only a single sealant application was performed, 69
percent of the group with sealed surfaces were sound, whereas 17 percent of the group
without sealants were sound. However, only 28 percent were completely retained after 15
years in the group with sealants [94]. Full retention of sealants can be checked visually,
tactilely, and radiographically.
There were concerns about partially lost sealant in that it may leave sharp margins that trap
food and eventually lead to caries [83]. An interesting systematic review aimed to evaluate if
the risk of developing caries in previously sealed teeth with fully or partially lost sealant
surpasses the risk in teeth that have never been sealed. Seven studies were included and the
participants were aged between 5- and 14-year-old. It was found that the risk of caries
development in previously sealed teeth after a four-year follow-up is less than or equal to that
for never-sealed teeth. In other words, teeth with partial or complete sealant loss are not at a
higher risk of developing caries compared to never-sealed teeth, and the relative risk (RR)
ranged between 0.693 and 1.083 [95]. This does not suggest that operators should be less
careful with the application technique of sealants or in the evaluation and maintainenace after
placement. This suggests, however, that a child should not be forbidden to get the benefits of
a sealant even if recall cannot be ensured [32,95].
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11. Esterogenicity
Bisphenol-A (BPA) is the precursor chemical component of bisphenol-a dimethacrylate (Bis-
DMA) and bisphenol-a glycidyl dimethacrylate (Bis-GMA), which are the most common
monomers used in resin composite restorations and resin-based sealants. It is known for its
estrogenic property with potential reproductive and developmental human toxicity [96,97].
BPA is not present in monomers as a raw material but as BPA derivatives that can sometimes
be hydrolyzed and found in saliva [34].
It has been reported in a systematic review that high levels of BPA were found in saliva
samples that had been collected immediately or one hour after resin-based sealant placement.
High levels of BPA were also detected in urine samples [98]. However, a report by the
American Dental Association and the American Academy of Pediatric Dentistry did not
support the occurrence of adverse effects after sealant placement and described the BPA
effect as a small transient effect [5,28].
Some studies have reported techniques, such as the immediate cleaning of the sealed surface,
or the removal of the oxygen inhibition layer of the unreacted monomer, which is present on
the outer layer of the sealant surface to reduce the amount of unreacted monomer. This can be
done using a pumice or a rotating rubber cup [98], to reduce the potential BPA exposure.