PIT AND FISSURE SEALANTS

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Presentations text content in PIT AND FISSURE SEALANTS

Slide1

PIT AND FISSURE SEALANTS

BY : PALKI BANSAL

PG FIRST YEAR

MODERATOR

DR. KAVITA

Slide2

REFERENCES:-

Pediatric dentistry

I

nfancy through Adolescence. 5

th

edition by: CASAMASSIMO. 2013

Richard J.

Simonsen.Pit

and fissure sealant: review of literature.

Pediatr

Dent. 2002;24(5):

393-414

James J.C, Kevin

J.D.Dental

sealants guidelines development: 2002-2014.

Pediatr

Dent 2015;37(2):111-5

Essentials of preventive and community dentistry. 4

th

edition by

Soben

Peter.2010

Slide3

M

aterial that is introduced into the occlusal pits and fissures of caries-susceptible teeth, thus forming a micromechanically bonded, protective layer, cutting access of caries-producing bacteria from their source of nutrients. (Simonsen RJ 2002 )

PIT AND FISSURE SEALANT

Slide4

PITS

small pinpoint depressions located at the junction of developmental grooves or at terminals of those grooves. (Ash and Nelson) 

FISSURE:

Deep clefts between adjoining cusps. These defects occur on occlusal surfaces of the molars and premolars, with tortuous configurations that are difficult to assess from the surfaces. (

Orbans

)

Slide5

Approximately 90% of the caries in permanent teeth of children occurs in pits and fissure, and approximately two- thirds of caries are on the occlusal surface alone. Similarly, the pits and fissures of primary teeth are also at risk because roughly 44% of carious lesion in the primary teeth affect the occlusal surfaces of molars.

Centres

for disease control and prevention: national health and nutrition examination surveys 1994-2004

Slide6

Why fissures are caries susceptible????

NEWLY ERUPTED, IMMATURE TOOTH ENAMEL

 HIGH ORGANIC CONTENT, MORE PERMEABLE  CARIES SUSCEPTIBLE

2. FISSURE MORPHOLOGY PROVIDE ENVIRONMENT FOR PLAQUE RETENTION AND BACTERIA PROLIFERATION.

3.ENAMEL IN PIT N FISSURES THINNER

 ACCELERATED

DEMINERALISATION

Slide7

MORPHOLOGY OF PIT & FISSURES

V – Type (34%)U – Type (14%)I – Type (19%)IK – Type (26%)Inverted Y – Type (7%)

Nagano(1961)

described following principal types of fissures, based on the alphabetical description of shape:

Slide8

Shallow, wide V & U shaped fissures

a. self cleansing

b. somewhat caries resistant.

Deep, narrow I shaped fissure

a. quite constricted

b. resemble bottle neck

c. narrow slit like opening

d. large base which extends towards

DEJ

e. caries susceptible.

K- shaped

fisssures

a. susceptible to caries

Slide9

DIAGNOSIS OF PIT & FISSURE CARIES:

In 1968, at an ADA sponsored conference on clinical testing of

cariostatic

agents  the criteria for detection and diagnosis of pit & fissure lesions were defined as follows :

Caries is present when the explorer catches or resists removal after insertion into a pit or fissure with moderate to firm pressure and when this is accompanied by one or more of the following signs of caries:

Slide10

a)   Softness at base of the area.

b) Opacity or loss of normal translucency adjacent to a pit or fissure as evidence of undermining or demineralization.

c)   Softened enamel adjacent to the pit or fissure that can be scraped away with the explorer.

Slide11

Slide12

HISTORY OF PIT AND FISSURE SEALANTS

In1905 Miller

used silver

nitratre

.

In 1923, Hyatt

reported a technique termed

“Prophylactic

Odontomy

in which non –carious fissures were prepared and restored with a silver alloy as a prophylactic measure.

1929,Bodecker

initially introduced an alternate method for caries prevention,

FISSURE ERADICATION.

Slide13

In 1955,

Buonocore

described the technique of

acid etching

as a simple method of increasing the adhesion of self- curing

methyl

methacrylate

resin material to dental enamel.

The first paper published on subject of pit and fissure sealant was in

1965 by

Cueto

and

Buonocore

.

First pit and fissure sealant

1971

named

Nuva

-seal(

LD. C

aulk, Milford. Del.)

INTRODUCED.

First

coloured

sealant 

1976

,

concise white

sealant by 3m company.

Slide14

TYPES OF PIT & FISSURE SEALANTS

1…ACCORDING TO CHEMICAL STRUCTURES OF MONOMERS

MMA

– Methyl

methacrylate

TEGDM

– Tri ethylene glycol

dimethacrylate

BPD

Bis

phenol

dimethacrylate

Bis

GMA

– Reaction product of

Bis

phenol A &

glycidyl

methacrylate

with a methyl

methacrylate

monomer.

ESPE

monomer

PMU

Propyl

methacrylate

urethane

Slide15

2…BASED ON GENERATIONSA) FIRST GENERATION SEALANTS -- UV light. eg:Nuva-lite B) SECOND GENERATION SEALANTS -- self cure/ chemical cure. eg: Concise white.C) THIRD GENERATION SEALANTS -- light cured/ visible ( blue) light. eg:Helioseal.D) FOURTH GENERATION SEALANTS -- fluoride releasing sealants. eg: Seal right (Pulodent)

Slide16

3. BASED ON FILLER CONTENT UNFILLED -- better flow -- more retention -- abrade easily FILLED -- resistance to wear-- may need occlusal adjustments

Slide17

4. BASED ON COLORCLEARTINTED/OPAQUECOLOURED

Slide18

5.Based on curingAUTOPOLYMERISINGLIGHTCURE

Slide19

Indications:

3. No radiographic or clinical evidence of interproximal caries .4. Possibility of adequate isolation from salivary contamination.

Stained pits and fissures with minimum appearance of decalcification or

opacification

.

Deep, retentive pits and fissures, which may cause wedging or catching of an explorer.

Slide20

Contraindications:

Well-coalesced, self-cleansing pits and fissures.

Radiographic or clinical evidence of

interproximal

caries in need of restoration.

Tooth partially erupted and no possibility of adequate isolation from salivary contamination.

Life expectancy of tooth is limited.

Lack of preventive practices.

Slide21

ELIGIBILITY FOR SEALANT APPLICATION:SELECTION OF PATIENT:-

2.BASED ON CLINICAL JUDGEMENT:AgeOral hygieneFamilial and individual history of dental cariesFluoride environment and historyDietary habitsTooth type and morphology

1.BASED ON AGE:

3-4 years of age for the primary molar sealant application.

6-7 years of age for the first permanent molar.

11-13 years of age for the second permanent molars and the premolars.

Slide22

3.BASED ON CARIES RISK:

Simonsen

in 1983

Group 1: Caries-free patients judged at no risk to decay.

Group 2: Patients judged to be at moderate risk to decay.

Group 3: Patients with rampant caries at a high risk to decay.

Slide23

Slide24

STEPS OF SEALANT APPLICATION

Slide25

ASSEMBLE ARMAMENTARIUM

Slide26

Position patient

Mandibular Maxillary

Slide27

1.Isolation of tooth:

The tooth should be isolated from salivary contamination by use of rubber dam or by cotton rolls and suctioning.Silverstone concluded that salivary contamination allows rapid precipitation of glycoprotein's onto the etched enamel, greatly decreasing the bond strength.Buonocore(1971) reported good retention of the sealant with cotton roll rather than rubber dam isolation.

Slide28

2.Tooth preparation:

Tooth surface is cleaned to remove plaque and debris from the enamel and pit and fissures of tooth.The early application technique - pumice and water mixture using a rotary brushVarious other cleaning methods have been tested. One is the Prophy-Jet, an early air abrasion system.

Slide29

The tensile bond strength of sealants prepared with various techniques was measured in a study by

De

Craene

et al.,1989

Air polishing with the

Prophy

-Jet followed by acid etching produced the highest bond strength of all groups tested.

A statistically significant higher mean bond strength was found after air polishing and acid etching compared to no cleansing prior to acid etching.

Slide30

Invasive technique

Garcia-Godoy and de Araujo,1994

demonstrated that the

Enameloplasty

Sealant Technique (EST)

allows a deeper sealant penetration and a superior sealant adaptation than the conventional sealant treatment without any mechanical enlargement of the fissures with a bur.

An increased surface area for sealant retention is readily evident in all samples treated with the EST.

Slide31

In another study, superior sealants were obtained when tooth surfaces were prepared by a bur, compared to air abrasion and conventionally prepared surfaces.(Wright et al,1999).

Enameloplasty

reduces

microleakage

of pit and fissure sealants, especially when load is applied to teeth, irrespective of which bur is used to enlarge the fissure. The application of occlusal force to the tooth produces significantly more

microleakage

, unless

enameloplasty

is performed

.

(

Zervou

et al,2000)

Slide32

Koh et al,1998, showed that exposure of enamel to NaF, SnF2 or APF prior to placement of unfilled or filled sealants has no effect on in vitro bond strength between the enamel and the sealants.

Koh

et al in 1995

showed that topical fluoride treatment has no clinical effect on retention of pit and fissure sealants.

Slide33

3.Acid etching tooth surface:

Silverstone in 1975

identified 3 basic patterns of etching:Type 1:Generalised roughening of enamel surface, but with distinct hollowing of prism centers and relatively intact peripheral regions.Type 2:Prism peripheries appear to be damaged. Prism cores are left projecting towards original enamel surface.Type 3:Show neither type 1 or 2 etching pattern but appear as generalised surface roughening.

Slide34

Buonocore 1955, initially used 85% phosphoric acid for 60 seconds for etching enamel.

In the early 1970s, it was believed that, due to the “prismless” nature of primary enamel, it would require double the etching time of permanent enamel, and this became the standard clinical procedure.

Primary enamel has been described as “prismless” by Gwinnett, 1973 . However, there is no evidence of prismless enamel (which would require a longer etching time) on occlusal surfaces (it is mostly found in cervical regions).

Slide35

Despite this, early recommendations for etching primary enamel were twice then-accepted time for permanent enamel (120 seconds vs 60 seconds).(Silverstone and Dogon 1976).

The first report comparing the retention on primary molars of the 120-second etching time

vs

60 seconds showed no difference in sealant retention.

(

Simonsen,1978)

A later report noted that, “Decreasing the etch time for primary molars has been found to decrease the chance of contamination, during etching. Additionally , the shorter etch time was far more acceptable to 3- and 4-year-old children.”

(Simonsen,1979)

Slide36

Silverstone(1974) found that 60 sec application of unbuffered solution of 37% phosphoric acid produced the most favourable conditions for bonding.Fuks et al(1984) and Eidelman et al(1984) showed respectively that a 20 sec etch provided similar resistance and retention rates when compared to a 60 sec etch.The most accepted times were given in IADR sealent symposium in 1991: 

Primary teeth

30

secs

.

Permanent teeth

20

secs

.

Slide37

4.Rinse and dry etched tooth surface:

Tooth is washed with water for about 30 seconds to remove all the etchant and then air-dried for 15 seconds with uncontaminated compressed air.

A properly etched tooth surface has a dull frosted appearance.

Slide38

5.Use of intermediate bonding layer:

Isolation is the key to the success of the clinical sealant procedure.

Salivary contamination, unless washed off thoroughly (and as some would do, re etch the area) leads to significantly reduced bond strengths.

Slide39

Feigal, came up with the novel concept that hydrophilic bonding materials that contain water, may, when applied under a sealant, minimize the bond strength normally lost when a sealant is applied in a moist environment.

Bonding agent under sealant on wet contamination yielded bond strengths equivalent to the bond strength obtained when sealant was bonded directly to clean, etched enamel. Bonding agent used without contamination yielded bond strengths significantly greater than the bond strength obtained when using sealant alone without contamination.

(Feigal and Hitt,1992)

Slide40

Retention and microleakage have shown improvement when a bonding agent is used: A 2-year clinical study comparing sealants done with intentional salivary contamination shows that sealant retention is possible on wet enamel if a bonding agent is used between enamel and sealant.(Chestnutt et al,1994)

In primary teeth, the effect of bonding agents on the

microleakage

and bond strength of sealant has been studied. The use of enamel-dentin bonding agents under sealant in moisture-contaminated conditions gave better results than applying sealant alone onto non contaminated teeth

(

Tolunoglu

et al,1999)

Slide41

Boksman(1993) carried out a clinical trial of sealants with and without bonding agent and found no benefit to the use of the bonding agent. The retention rates for the sealants were 77% for Concise with Scotchbond 2, 84% for Concise with no bonding agent; 77% for Prisma Shield with Universal Bond; and 77% for Prisma Shield with no bonding agent.

A study by

Arzu

Pinar et al (2005)

observed that the use of bonding agent as an intermediary layer between enamel and sealant did not affect sealant success during a 24-month period.

Slide42

Based on the results observed in several studies, the use of bonding agent as an intermediary layer between enamel and sealant did not affect sealant success. In situations in which control of saliva and isolation is impossible the use of bonding for increasing the quality of fissure sealant therapy is useful.

Slide43

6.Application of

sealent:

In mandibular teeth , apply the

sealent

distally and allow it to flow

mesially

with the converse being true for maxillary teeth.

During the application

of sealant care should

be taken to prevent the

incorporation of air

bubbles.

Slide44

7.Curing

Done according to the

manufacturer’s direction.

Once the material is cured fully, it is examined very carefully with an explorer to make sure that in the sealant application technique:

All the fissures and pits are covered

All the excessive material has been removed.

Material is firmly adherent to the enamel surface.

Slide45

Now a days lasers are used for curing due to the following advantages :

Reduction in setting time.

Control of specific radiation energy wavelengths.

Control of area of exposure.

Decrease in %age of

unpolymerized

resin.

Slide46

8.Evaluation of occlusion:

Evaluate occlusion of sealed tooth surface with articulating paper to determine if any excessive sealant is present and needs to be removed.

A small discrepancy in occlusion in case of unfilled sealant is easily tolerated as the cement abrades away but in case of filled resin sealant occlusal adjustment is must to avoid discomfort.

Slide47

9.Recall and re-evaluation:

Sealants must be thoroughly checked at subsequent recall appointments as to ensure that:

The sealant is still firmly adherent to the tooth and

The sealant material has not been lost.

Thus, if there is any of the sealant material lost then it must be added during this time.

Slide48

Effectiveness of sealants:

For the sealants to be very effective, first of all it should be retained which depends upon the following factors:

Technique of sealants application

The type of sealant material used and

The morphology of the surface of the tooth to which the sealant is applied to cover the pits and fissures.

Slide49

Retention and caries prevention:

Horowitz’s landmark Kalispell

study (1977)

.

In the 5-year report of this study, the authors reported 42% complete retention at 5 years. Horowitz also noted that teeth with sealant partially missing had a lower incidence of caries (7%) than paired unsealed control teeth that were not sealed (41% caries).

Slide50

Wendt and

Koch (1988)

reported on teeth sealed over a 10-year period.

They found that after 8 years, about 80% of the sealed fissures showed total sealant retention and no caries.

Another 16% of the sealed occlusal surfaces showed partial retention and no caries.

After 10 years, only 6% of the sealed occlusal surfaces showed caries or restorations

Slide51

A 15-year study of the single application of a

colored

(white)

autopolymerizing

pit and fissure sealant found 28% complete retention and 35% partial (

noncarious

) retention on permanent first molars. In a matched-pair analysis, carious or restored surfaces made up 31% of the surfaces in the sealed group and 83% in the unsealed group

.(Simonsen,1991)

Slide52

Cost effectiveness:

At the 10-year point of a 15-year study, it was found that it is 1.6 times as costly to restore the carious lesions in the first permanent molars in an unsealed group of 5- to 10-year-old children living in a fluoridated area than it is to prevent, with a single application of pit and fissure sealant, the greater number of lesions observed if pit and fissure sealant is not utilized

(

Simonsen

RJ,1989)

Slide53

Estrogenicity issue:

A recent study on the

estrogenicity

of resin-based dental composites and sealants by

Olea

and

coworkers

in Granada,1996, Spain

, started a controversy that resulted in considerable confusion and doubt in the minds of many dentists and consumers alike about the safety of pit and fissure sealant.

Concern was raised about the safety of monomers leached out of these materials.

Slide54

The conversion of monomers during the curing process of a sealant is incomplete, thus residual monomers can leach out of the cured resin.

BPA released orally from a dental sealant may not be absorbed or may be present in non detectable amounts in systemic circulation. The concern about potential

estrogenicity

of sealant may be unfounded

.(Fung et al 2000)

Slide55

The parental concern about the

estrogenicity

of sealants is unfounded based on the presently-available evidence. It should also be remembered that

none of the dental sealants that carry the ADA Seal release detectable BPA.

Slide56

Fluoride used with sealants and fluoride-containing sealant:

In an evaluation after 4 years of the combined use of fluoride and dental sealants, the overall proportion of sealants retained on occlusal surfaces of first molars after an average of 2 years is 92%. This study suggests that pit and fissure sealants confer additional caries-preventive benefits beyond those of fluoride therapy alone

.(

Selwitz

et al,1995)

Slide57

In an analysis of fluoride release from fissure sealants,

Garcia-Godoy,

Summitt

and

Donly

(1997)

found that all the fluoridated sealants tested released measurable fluoride.

However, the greatest amount of fluoride was released in the first 24 hours after mixing, and the fluoride release fell sharply on the second day and decreased slowly for the last days.

Slide58

Options: filled vs unfilled; colored vs clear; autocure vs light-initiated:Filled vs unfilled:

Penetration, is inversely proportional to the viscosity. Thus, it could be reasoned that an unfilled resin will penetrate deeper into the fissure system, and, therefore, perhaps be better retained.

In a study comparing unfilled and filled sealant in the mouth, an unfilled light-cured resin was significantly better retained than a filled light-cured resin.

(Rock et al,1990)

Slide59

Colored vs clear:

In March of 1977, the first

colored

sealant (3M’s Concise White Sealant) was introduced .

Advantages :

Easier to see the sealant during application, and faster to assess retention with a white sealant.

Documentation of retention is much easier over long time periods with a

colored

sealant.

Some have argued against use of an opaque

color

as it precludes continual examination of the sealed fissure.

Slide60

Autocure vs light-initiated:

 

Autopolymerizing

resins generally performed better than the early ultraviolet light-initiated resin sealant—84% complete retention at 2 years compared to 75% in one study. When the visible light-initiated resins were introduced and compared to the autopolymerising sealant, no significant difference was found in retention over 31 months. 

De

Craene

and

coworkers

(1989)

showed that a visible

lightcured

sealant (

Helioseal

) appears to be as good as the self-cured sealants and better than the UV light-cured products.

Slide61

Glass ionomer materials as sealants:

The logical assumption that a material that

releases fluoride

, such

as a glass

ionomer

cement, would provide an

added benefit

to the retentive blocking of the fissure by a resin sealant, has been tested many times with various glass

ionomer

materials, sometimes in direct comparison with resin materials.

Slide62

Glass-

ionomer

(

polyalkenoate

) cements have documented high levels of fluoride release

. However

, used as a pit and fissure sealant, the traditional glass-

ionomer

cements have shown very poor retention rates as well as leakage even when fully retained

.

(

Boksman,1987

)

In a study reported by

Boksman

et al

, a comparison of the study’s 6-month complete retention rates of 92% for Concise white light-initiated sealant and 2% for the Fuji III glass

ionomer

sealant, suggests, according to the

authors,that

the routine use of the Fuji III glass

ionomer

as a fissure sealant is unreliable.

Slide63

Whether the development of the

resin-modified glass-

ionomer

(RMGI)

cements can challenge the resin sealants in terms of retention remains to be seen.

But early indications are that the RMGI wears markedly more than the resin sealant.

-

W

inkler et al, 1996

Slide64

(

Forss

et al 1998)

conducted a

7-year study looked at retention of a glass-

ionomer

cement and a resin-based fissure sealant and effect on carious outcome.

The aim of this study was to compare the retention and caries preventive efficacy of glass-

ionomer

(Fuji III; GIC) and light-cured resin-based (Delton; LCR) fissure sealants.

Slide65

On the sealed occlusal surfaces, 10% of GIC and 45% of LCR sealants were totally present and 9% of GIC and 20% of LCR sealants partially present.

Twenty three(24

%) of the occlusal surfaces sealed with GIC and 16 (17%) of those sealed with LCR were carious or

filled.

Slide66

Kervanto

-

Seppala

S et al (2000)

concluded that glass-

ionomer

sealants, whether resealed or not, cannot be as cost-effective as resin-bonded sealants when the expense of placement in time (and thus cost) is used as the basis of efficacy.

Slide67

Current status:Fluorescing Pit and Fissure sealent

Use of UV pen light: fluoresces a blue/white color.Visual verification of sealent margins at time of placement and recall . Eg : Delton Seal-N-Glo

Slide68

Wetbond pit and fissure sealent

Bonds chemically and micromechanically to the moist tooth.First pit and fissure resin sealent that can be applied in moist field.

Slide69

Pit and fissure

sealent with ACP

Light cured

sealent

that

contains “smart material”

Amorphous Calcium Phosphate(ACP).

More resilient and

flexible,creating

stronger long lasting

sealent

.

Eg:Aegis

pit and

fisure

sealent

.

Slide70

American Academy of Pediatric Dentistry (AAPD) guidelines Recommendations for Pit and fissure sealants (2008):

Sealants should be placed into pits and fissures of teeth based upon the

patient’s caries risk

, not the patient’s age or time lapsed since tooth eruption.

Sealants should be placed on surfaces judged to be at

high risk or surfaces

that already exhibit incipient carious lesions to inhibit lesion progression.

Follow up care

, as with all dental treatment, is recommended.

Slide71

Sealant placement methods should include

careful cleaning

of the pits and fissures without removal of any appreciable enamel. Some circumstances may indicate use of a minimal

enameloplasty

technique.

 

A

low-viscosity hydrophilic

material bonding layer, as part of or under the actual sealant, is recommended for long-term retention and effectiveness.

Glass

ionomer

materials

could be used as

transitional

sealants.

Slide72

PREVENTIVE RESIN RESTORATIONS:

A PRR is a conservative treatment that involves limited excavation to remove the carious tissue , restoration of the excavated area with a composite resin , and application of a sealant over the surface of the restoration and remaining, sound, contiguous pits and fissures

. (

Ripa

et al 1992)

Also called

CONSERVATIVE ADHESIVE RESIN RESTORATION

.

First reported by

Simonsen

and

Stallard

(1978)

Slide73

Types of PRR:

1.TYPE A : Deep pit and fissure susceptible to caries.The preparation size is very smallUnfilled resin or sealant is used to restore the preparation of carious lesions involving round bur of size ½ or less

Slide74

2.Group B : Minimal exploratory carious lesion.Since the caries can be explored the preparation needs to be extended.Preparation size is by size 2 round bur.The restoration requires some filler to be added to the unfilled resin.

Types of PRR:

Slide75

3.TYPE C:Isolated carious lesion.The presence of caries is definite and requires considerable preparation.Larger size bur is used following which a small bevel is placed at cavosurface margin.

Types of PRR:

Slide76

Advantages:

Conservation of Tooth Structure

Aesthetics

Flexible preparation design

Ease and speed of placement

Slide77

Procedure:

Place a rubber dam to prevent saliva contamination during tooth preparation

Clean surface of tooth with flour of pumice and a bristle brush

Open into the area of carious lesion with a small round bur (1/2, 2)

Remove only carious lesion

Slide78

Open adjacent grooves only when necessary to insure they are caries free; use the tip of a diamond or ¼ or ½ round bur, maintain contour of the

occlusal

surface

Etch the surface of the tooth with a 37% phosphoric acid solution for 15 SECONDS; shorter time than sealant because in dentin , etchant will penetrate farther and it can end with a hollow demineralized spot

Rinse with copious amounts of water to remove etchant

Slide79

Gently blow air over the surface of the tooth to remove excess water, but leave the surface moist with H

2

O; don’t want to dehydrate the dentin

Place dentin bonding agent over entire etched surface using a brush

Blow air over area to evaporate solvent

Apply second coat and air dry

Cure for 20 seconds

Place

flowable

composite in the deepest area of restoration

Slide80

Disperse to other parts of the preparation using the tip of an explorer

Cure for a minimum of 40 seconds

Place sealant material over restored area and adjacent intact etched pits and fissures.

Check the occlusion with articulating paper and adjust as necessary.

Periodically reevaluate , repair and reapply as necessary.

Slide81

PRR are an extension of the sealant technique that allow for caries control with minimal loss of tooth structure

.

This method is indicated where caries within a fissure has just reached the dentine.

Under ideal circumstances the fissure sealants can successfully prevent progression of caries

(

Thylstrup

and

Fejerskov

, 1994)

Slide82

For early decay, where space allows, glass

ionomer

veneered with unfilled resin should be used. The main difficulty in determining the optimal form of management for an early decay lesion is the diagnosis of state of the fissure.

Management of doubtful

occlusal

fissures, with use of air abrasion techniques to open up all suspect fissures and grooves does not fit well with current minimal intervention philosophy, even though it may be easiest solution for the practitioner.

Slide83

THANK YOU


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