MAKALAH PEDODONSIA

PERAWATAN PREVENTIF RESIN RESTORATION (PRR)

Oleh

Agis Dwi AprilI

NIM 191611101087 / 151610101061

Dosen Pembimbing
drg. Dyah Setyorini, M. Kes

Bagian Pedodonsia
Rumah Sakit Gigi dan Mulut
Universitas Jember
2020
 BAB 1
PENDAHULUA
N

1.1 Latar Belakang

Restorasi pencegahan adalah suatu perawatan pencegahan yang
merupakan pengembangan dari pemakaian sealant pada permukaan oklusal, yaitu
integrasi dari pencegahan karies dengan sealant dan penambalan karies dengan
resin komposit pada permukaan yang sama. Lesi awal permukaan gigi
dihilangkan dengan preparasi seminimal mungkin, ditambal kemudian untuk
mencegah terjadinya karies di masa mendatang permukaan tambalan diberi
sealant (Mathewson and Primosch, 1995).
Tujuan dari dari restorasi pencegahan adalah untuk menghentikan proses
karies awal yang terdapat pada pit dan fisur, terutama gigi molar permanen yang
memiliki pit dan fisur, sekaligus melakukan tindakan pencegahan terhadap karies
pit dan fisur yang belum terkena karies pada gigi yang sama. Pit dan fisur yang
dalam dan sempit atau pit dan fisur yang memiliki bentuk seperti lebar botol,
secara klinis merupakan daerah yang sangat mudah terserang karies, karena
sewwaktu gigi disikat bagian dalam pit dan fisur tidak dapat dijangkau oleh bulu
sikat gigi (Yoga, 1997).
Preventive Resin Restoration (PRR) merupakan suatu prosedur klinik yang
digunakan untuk mengisolasi pit dan fisur dan sekaligus mencegah terjadinya
karies pit dan fisur dengan memakai teknik etsa asam. Teknik ini diperkenalkan
pertama kali oleh Simonsen pada tahun 1977, meliputi pelebaran daerah pi dan
fisur kemudian pembuangan email dan dentin yang telah terkena karies sepanjang
pit dan fisur. Menurut Simonsen, terdapat tiga tipe bahan restorasi pencegahan
dengan resin (tipe A, tipe B, tipe C) yang diklasifikasikan berdasarkan pada
perluasan dan kedalaman karies. Klasifikasi ini untuk menentukan bahan restorasi
yang dipakai (Yoga 1997).
1.2 Rumusan Masalah:
1. Apa indikasi dan kontraindikasi dilakukan perawatan Preventive
Resin Restoration (PRR)?
2. Apa saja tipe-tipe perawatan Preventive Resin Restoration (PRR)?
3. Bagaimana prosedur atau teknik perawatan Preventive Resin Restoration
(PRR)?

1.3 Tujuan
1. Untuk memahami indikasi dan kontraindikasi dilakukan perawatan
Preventive Resin Restoration (PRR)
2. Untuk memahami tipe-tipe perawatan Preventive Resin Restoration (PRR)
3. Untuk memahami prosedur atau teknik perawatan Preventive
Resin Restoration (PRR)
 BAB 2
PEMBAHAS
AN

2.1 Indikasi dan kontraindikasi Preventive Resin Restoration (PRR)

Indikasi:
a. Gigi molar permanen pertama muda (kurang dari 9 tahun)
b. Gigi molar permanen kedua muda (kurang dari 14 tahun)
c. Gigi premolar pertama dan kedua muda (kurang dari 13 tahun)
d. Lesi karies belum mencapai pulpa
e. Belum ada keluhan spontan
Kontraindikasi:
a. Diperlukan restorasi karies interproksimal
b. Melibatkan karies yang luas, dalam, dan karies multiple pada permukaan
gigi (Swift, 1987)
c. Self cleansing yang baik pada pit dan fissure yang dangkal
d. Gigi erupsi hanya sebagian dan tidak memungkinkan untuk dilakukan
isolasi
e. Umur erupsi gigi lebih dari 4 tahun

2.2 Tipe-tipe perawatan Preventive Resin Restoration (PRR)

Ada 3 tipe preventive resin restoration berdasarkan luas dan dalam lesi
kariesnya,yaitu :
1. Tipe A : karies sebatas enamel

Tipe A karies masih mengenai enamel

 2. Tipe B : karies melibatkan dentin yang kecil dan terbatas

Tipe B karies yang mengenai sedikit dentin

3. Tipe C : karies yang melibatkan dentin yang lebih luas dan

dalam.

Bahan yang digunakan :

Menurut Simonsen, terdapat tiga tipe bahan restorasi pencegahan dengan
resin (tipe A, tipe B dan tipe C) yang diklasifikasikan berdasarkan pada perluasan
dan kedalaman karies. Klasifikasi ini untuk menentukan bahan restorasi yang
akan dipakai (Simonsen 1980; Yoga,1997).
Bahan yang dipakai adalah bahan sealant tanpa partikel pengisi (unfilled)
untuk tipe A, resin komposit yang dilute untuk tipe B dan filled resin komposit
untuk tipe C. Dengan perkembangan teknologi ditemukan bahan yang lebih tahan
terhadap pemakaian, pengerasannya diaktivasi sinar yakni resin komposit untuk
gigi posterior. Generasi baru dari bahan tersebut akan mempertinggi keberhasilan
restorasi resin pencegahan. Selain resin komposit, dipakai juga bahan tambal lain
agar dapat didapat kekuatan yang lebih besar. Seperti pada teknik glass ionomer
resin preventive restoration, glass ionomer preventive restoration dan sealant-
amalgam preventive restoration

2.3 Prosedur perawatan

PRR Tipe A
Menggunakan unfilled sealant
Tenik aplikasinya :
 1. Bersihkan permukaan oklusal
2. Isolasi gigi dengan cotton rolls atau rubber dam
3. Hilangkan decalcified enamel pada pit & fissure menggunakan low speed
round bur (no ½ atau ¼)
Pada pembuangan jaringan karies, maka daerah pit dan fisur yang buang
adalah daerah yang mengalami dekalsifikasi atau yang dicurigai telah
terjadi karies dengan menggunakan round bur kekuatan rendah. Daerah
retensi tidak diperlukan karena restorasi ini mendapatkan perlekatan ke
jaringan dengan tehnik etsa asam. Tujuannya adalah untuk membuang
seluruh jaringan karies dan struktur gigi seminimal mungkin.
4. Selanjutnya dilakukan profilaksi dengan pumis.
Dilakukan menggunakan pumis yang tidak mengandung fluor sehingga
permukaan email benar-benar bersih dan dibur sebelum dietsa. Sebagai
alternatif untuk memperoleh tujuan yang sama, dapat menggunakan sikat
gigi dan pasta gigi. Dengan metode ini nilai retensi yang diperoleh
sebanding dengan metode menggunakan profilaksis pumis (Yoga,1997).
5. Etsa 20’-60’, bilas 20’ dan keringkan 15’.
Tahap selanjutnya adalah penetsaan asam menggunakan asam fosfat 37%
yang diletakkan pada permukaan email di oklusal gigi (pit dan fisur).
Pengetsaan ini menghasilkan pori-pori yag memungkinakan infiltrasi
nikroskopis resin ke dalam permukaan gigi yang kemudian resin akan
berpolimerisasi dan membentuk ikatan dengan gigi (Simonsen 1980;
Yoga, 1997).
6. Aplikasi sealant, hindari gelembung
7. Polimerisasi sinar 20’(atau sesuai aturan pabrik)

 PRR Tipe B
Menggunakan diluted komposit resin
Teknik aplikasinya :
1. Bersihkan permukaan oklusal
2. Isolasi gigi dengan cotton rolls atau rubber dam
 3. Hilangkan karies dengan low speed bur
4. Bersihkan dentin dan sisa serbuk gigi dengan air sampai permukaan dentin
bersih
5. Aplikasikan liner kalsium hidroksida Ca(OH)2 pada permukaan dentin
yang terbuka
6. Etsa 20-60 detik, bilas 20 detik dan keringkan 15 detik
7. Aplikasi bonding agent pada dinding gigi yang dpreparasi, disinar 20 detik
8. Aplikasikan bahan resin komposit, disinar 20 detik
9. Aplikasi sealant pada seluruh permukaan oklusal, disinar 20 detik
10. Oklusal adjustment dan dilakukan pemolesan

 PRR Tipe C
Untuk lesi karies yang dalam dan membutuhksn preparasi mendalam pada dentin.
Bahan restorasi menggunakan filled composit resin dan Glass Ionomer Cement
(GIC) serta sebagian besar membutuhkan anastesi lokal.
Teknik aplikasinya :
1. Bersihkan permukaan oklusal secara menyeluruh
2. Isolasi gigi dengan cotton rolls atau rubberdam
3. Gigi di anastesi lokal, hilangkan karies dengan low speed bur, permukaan
cavosurface margin enamel dibevel.
4. Bersihkan dentin dan sisa serbuk gigi dengan air sampai permukaan dentin
bersih
5. Aplikasikan liner kalsium hidroksida Ca(OH)2 pada permukaan dentin
yang terbuka
6. Aplikasikan bahan Glass Ionomer Cement (GIC), ditunggu hingga setting.
7. Aplikasikan bahan Etsa pada permukaan oklusal selama 60 detik, bilas 20
selama 20 detik dan keringkan 15 detik.
8. Aplikasi bonding agent pada gigi yang telah dipreparasi, disinar selama 20
detik
9. Aplikasikan komposit resin dan disinar selama 20 detik
10. Aplikasi sealant pada seluruh permukaan oklusal, disinar 20 detik
 11. Oklusal adjustment dan dilakukan pemolesan
Pada saat mengaplikasikan PRR, lakukan isolasi daerah kerja dengan
menjaga permukaan gigi agar tetap kering agar keberhasilan retemsinya baik.
Isolasi dapat dilakukan dengan pemberian cotton roll atau rubber dam. Namun
pada anak kecil, mungkin kurang nyaman jadi memerlukan upaya lebih oleh
operator untuk menjaganya.
Untuk preparasi kavitasnya gunakan bur intan bulat kecil dengan
kecepatan rendah untuk membuang dentin karies sehingga daerah ini harus tidak
berwarna dan terasa keras jika di cek dengan sonde. Selain itu, karies lunak yang
menutupi pulpa dibuang, baik mengguanakan bur kecepatan rendah atau
ekskavator tajam.
Pada saat pelapikan (liner) setiap dentin yang terbuka gunakan dengan
Ca(OH)2. Kavitas yang dalam, dapat diberi pelapik kedua berupa semen ionomer
dan lakukan secara hati-hati agar dinding email yang akan teretsa tidak tertutup.
Kemudian dinding email dan permukaan oklusal di etsa, dan dicuci setelah
dilakukan pengeringan selama 20 detik.
Dalam penumpatan atau pengaplikasian gunakan resin komposit untuk
gigi posterior, dan bahan tidak akan terpolimerisasi dengan baik jika ketebalan
resin melebihi 2mm sehingga bahan harus diaplikasikan selapis demi selapis, serta
setiap lapisan dipolimerisasi dengan sinar. Kemudian aplikasikan bahan penutup
ceruk atau pit dan fissure (unfilled resin) dan meratakannya dengan sonde.
Pastikan juga tidak ada gelembung udara dan kelebihan bahan dapat diambil
dengan butiran kapas sebelum dipolimerisasi.
Setelah pengaplikasian resin selesai, lakukan evaluasi dengan cara
mengecek oklisi dengan articulator paper, jika ada kelebihan buang dengan bur
dan pulas akhir komposit. Sealant harus diperiksa ulang setiap 6 bulan dan jika
sealant hilang maka prosedur diatas dapat diulang kembali.
 BAB 3
PENUTUP

Kesimpulan
Preventive Resin Restoration Merupakan pengembangan penggunaan
sealant oklusal, yang menyatukan cara pencegahan terapi sealant untuk pit dan
fissure yang rentan karies dengan terapi restorasi karies menggunakan resin
komposit yang terjadi pada permukaan oklusal yang sama. Ada 3 tipe preventive
resin restoration berdasarkan luas dan dalam lesi kariesnya,yaitu :
Tipe A : karies sebatas enamel
Tipe B : karies melibatkan dentin yang kecil dan terbatas
Tipe C : karies yang melibatkan dentin yang lebih luas dan dalam
 Daftar Pustaka

Kuliah pakar drg. Rudy Budiraharjo Sp. KGA tentang PRR (Preventive Resin
Restoration)
Simonsen, RJ. 2006. Preventive Resin Restoration and sealants in light of crrent
evidence. J Am Dent Assoc 100 (4). 535-9
Swift Edward. 1987. JADA: preventive resin restoration. Vol 114. 819-821.
 Dent Clin N Am 49 (2005) 815–823

Preventive Resin Restorations and

Sealants in Light of Current
Evidence
Richard J. Simonsen, DDS, MS
Restorative Dentistry, Arizona School of Dentistry & Oral Health,
5850 East Still Circle, Mesa, AZ 85206, USA

The 1970s were years of huge potential for change in clinical

de ntistry, part i cularly inh t efi elds of preventive dentistr , operative
dentistry, andy clinical orthodontics. These three disciplines were
particularly fertile areas for the application of benefits of the acid-etch
technique developed by Buonocore [1]. Nevertheless, change in clinical
procedures does not occur easily, and the benefits wrought by the
landmark work of Buonocore were adopted painfully slowly into daily
clinical dental practice.
In the mid-1960s, Buonocore and others [2–4] published interesting
re port s on the potential use of the acid-etc h technique a a caries-
preventive
s measure that came to be known as the pit and fissure sealant
technique. This procedure was introduced commercially in 1971 by the
L.D. Caulk Company (Milford, Delaware) when the first ultraviolet-
light- cured pit and fissure sealant, Nuva- Seal, was launched in
February of that year. In subsequent months and years, several other
manufacturers introduced their own sealants, primarily of the
autocuring type. The technique was the subject of many laboratory and
clinical trials that were generally positive in terms of retention and caries
prevention [5]. Nevertheless, the profession was reluctant to adopt this
procedure, and in 2005, the pit and fissure sealant is perhaps the most
tested yet most underused technique in clinical preventive dentistry [6–
8]. Buonocore’s work had an even greater potential for impact on clinical
restorative dentistry than on preventive dentistry, as Buonocore himself
had predicted in his seminal article in 1955 [1]. These changes quickly
followed the introduction of pit and fissure sealant as a preventive
procedure.
G.V. Black is the father of operative dentistry. His work on dental
a
malgam t
and on sys ematiz ing the class ification of cavity p eparations
was of immense impact r in operative dentistry for most of the last
century. His work was regarded with almost biblical reverence by
teachers of operative
 E-mail address: rsimonsen@cox.net

0011-8532/05/$ - see front matter © 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2005.05.002 dental.theclinics.com
816 SIMONSEN

dentistry at schools of dentistry around the world. When the acid-etch

technique made possible an alternative minimally-invasive option for
the treatment of small or incipient pit and fissure carious lesions, a
technique
that came to be known as the preventive resin restoration (PRR), it was
met with skepticism at best, and outright hostility at worst, in the
operative and pediatric dentistry departments of many universities. I
can remember in 1982 when the Department of Operative Dentistry at
the University of Connecticut was teaching the PRR while the
Department of Pediatric Dentistry at the same school continued to teach
the Class I amalgam for incipient lesions in the pit and fissure surfaces of
posterior teeth. This conflict within institutions is common when new
technology is assessed in different ways by different faculty. In
orthodontics, the benefits of bonding brackets were more readily
apparent, and the transition from cementing bands to bonding brackets
occurred more smoothly [9].

Pit and fissure sealants and preventive resin restoration

The PRR was born of the clinical experience with sealants in the early
1970s. I was fortunate to spend 6 weeks with Harald Ulvestad and Bjo¨rn
Zachrisson in 1971 at the University of Oslo, Norway, after graduation
from the University of Minnesota School of Dentistry. These enthusiastic
and distinguished colleagues stimulated thoughts that, combined with
cli- nical experiences with sealants in subsequent years, led to the
development of the PRR from 1972 to 1975.
Zachrisson was the pioneer in adopting the acid-etch technique to
bonding brackets in orthodontics, and Ulvestad was contemplating
using a diluted-composite material as a more wear-resistant sealant
option [10].
The use of sealants preventively was clearly beneficial as shown by the
early work of Cueto and Buonocore [4], which has been supported by
hundreds of subsequent studies and reams of reports. The dilemma of
having to prepare the significantly invasive Class I amalgam preparation
for teeth deemed inappropriate for sealants because of an incipient
lesion led to the thought that a more conservative option must be found.
The Class I amalgam preparation is designed to accommodate the
strength deficiencies of the amalgam material; therefore, tooth
preparations are always made into the dentinal layer rather than leaving
some enamel, even if the caries is in enamel only. The reason is that
amalgam is a brittle material and weak in a thin layer. Vital tooth
structure is removed simply to provide strength for the restorative
material. Similarly, the Class I amalgam requires ‘‘extension for
prevention,’’ which removes adjacent noncarious pits and fissures in a
preventive move to limit the chances of an additional caries attack on
the adjacent surfaces.
The chasm between the beneficial effects of a noninvasive sealant and
t ex tensively invasive Class I amalgam p eparation (at least when
he
compared
r with the sealant) was huge in microscopic terms. Cutting
through enamel
PRRs AND SEALANTS IN LIGHT OF CURRENT
EVIDENCE 817

into dentin can be the first step in the eventual crowning or loss of the
tooth. Losing the enamel link between cusps makes the cusps
susceptible to movement during mastication. This microscopic
movement leads to
cracks in the adjacent enamel. These cracks propagate over time, and,
eventually, a cusp fractures, leading to a more radical operative
procedure. The life cycle of the first permanent molar, that is, the cycle
of restoration and re- restoration, is one that is set up soon after eruption
of the tooth if conventional Black cavity preparations are used [11].
Perhaps the greatest service any dentist can provide to a patient is
preventing any restorative treatment to the first permanent molars. The
acid-etch technique and the new bondable materials provided a
minimally-invasive option that theretofore had not been possible. The
concept of Black’s cavity preparation rules for the Class I amalgam were
made obsolete by the ability to change cavity preparations for incipient
pit and fissure lesions from the complex rules of Black, that
accommodated amalgam’s deficiencies, to simply the removal of
diseased tooth structure. The practice of extension for prevention
became anathema to PRR cavity preparation with the advent of the acid-
etch technique and bonded materials. Nevertheless, many years passed
before the PRR was completely accepted by clinicians and dental schools
as the preferred treatment option for incipient posterior carious lesions.
The first publication on the PRR used the term sealant-restorations
[12] for the minimally invasive procedure and was the result of the first
years of research into a less destructive Class I restorative procedure.
The technique was titled ‘‘sealant-restoration,’’ because it was a
restoration using sealant as an integral part of the procedure
(distinguishing it from a conventional preventive sealant in that carious
tooth structure was removed). Thereafter, the term preventive resin
restoration was used [13,14] because it was thought that the term sealant-
restoration was somewhat oxymoronic (as, perhaps, some would say of
the term PRR). The term was not meant to confine the category to resin
restorative materials but used merely to indicate that this was a new
concept using available bondable materials that was restorative while
preventive (in terms of minimal amounts of tooth reduction and the use
of a preventive material as an integral component of the procedure). The
major benefit of the procedure was the minimally-invasive effect of
cavity preparations that abandoned Black’s principles and removed only
diseased tooth structure while using Buonocore’s acid-etch principles
and Bowen’s work in the development of resin materials [15]. The PRR
was not well received by the adherents of Black’s principles. Three-year
results were published in the Journal of the American Dental Association
[16] only after the author appealed a reviewer’s decision to reject the
article because, ‘‘Everyone knows that composites cannot work in the
posterior.’’ Neverthe- less, the PRR as a minimally-invasive procedure
has stood the test of time, and the basic philosophy of conservation of
tooth structure for maintenance of the inherent strength of the tooth
remains unchallenged today.
818 SIMONSEN

The original three types of PRR (type A, B, and C) from 1977 were
modified slightly and updated in 1985 [17] with the definition of types 1,
2, and 3 PRR. Of the different types, the type 3 PRR is the one that is
accepted as the generic PRR. The other two types are basically variants
that comprise exploratory preparations that do not penetrate enamel and
that use a pit and fissure sealant as the material of choice (type 1). The
type 2 PRR involves a restorative procedure in which replacement of the
tooth structure and sealing of adjacent unprepared pits and fissures is
accomplished using a diluted composite resin or, as it would be called
today, a flowable resin composite. Until recently, any use of a diluted
composite or a flowable resin composite has been somewhat of a
compromise in the two needs (restorative and preventive) for a PRR. In
the restorative component, a flowable resin composite compared with a
full-strength posterior composite will have less filler load (and thus less
strength). In the preventive component, the flowable resin composite,
being more highly filled than a sealant, will lose some of the penetration
effect of the sealant. Penetration of a sealant into pits and fissures is a
crucial aspect of success [18]. Because penetration is inversely
proportional to the viscosity of the material being used, a flowable
material compromises the PRR when compared with the type 3 version
using the two materialsdthe posterior composite for the replacement of
lost tooth structure, and the sealant as a preventive material placed over
the composite and into adjacent unprepared pits and fissures.
In the type 3 PRR, two materials are useddone to restore and one to
prevent future caries. Both materials are used in their primary roles as
restorative and preventive materials; therefore, there is no compromise
of
function of the two materials. Recent developments in flowable materials
seem to be heading in the direction of greater strength, but the
penetration of the material in its role as a pit and fissure sealant in a
PRR is still of concern. Use of a self-etching adhesive (SEA) before a
wear-resistant flowable material could be the treatment of choice in the
future.
When use of the PRR was first documented, there was concern about
etching dentin. Subsequently, the total etch technique and SEAs have
become available whereby the etching step is combined with the
application of a primer and an adhesive. Although full documentation of
the new adhesives remains to be completed, if it is assumed that the new
materials will be successful, the type 3 PRR would be performed as
follows:

1. Isolate the tooth with a rubber dam. Anesthesia is generally

preferable unless the extent of the caries is known to be minimal, and
the patient, in the operator’s experience, will be comfortable without
anesthesia.
2. Using the smallest bur possible (the 003 or 1/16th bur from Brasseler
[Savannah, Georgia] is an example of the smallest ultra-small round
bur), the fissures are cleaned and carious areas confirmed. Although
 other tapered burs and diamonds may work well, it is more difficult
to get access to caries (eg, along the dentino-enamel junction under
an enamel margin)
PRRs AND SEALANTS IN LIGHT OF CURRENT
EVIDENCE 819

with a tapered bur, and the deeper the preparation gets, the wider
it becomes when a tapered bur is used. This effect is not true with
a roundbur.
3. The carious tooth structure is removed with the small round bur,
going up in size of the bur as necessary for removal of all decayed
tooth structure. Other burs are available, and some operators may
prefer to use air abrasion for this step. Although access openings are
kept as small as possible, carious tooth structure must be removed
carefully along the dentino-enamel junction, which may be difficult
to access without increasing the cavity opening. Once all carious
tooth structure has been removed and any fissures that may be
suspicious for carious activity have been explored, the restoration
can commence.
4. A contemporary SEA material is applied into and around the cavity
preparation, including areas where the sealant layer will be applied,
and is then dried or thinned thoroughly, followed by light-curing,
depending on the manufacturer’s instructions. The restorative resin
composite is applied with an applicator of choice. These small
preparations can trap air bubbles unless one operates with care and
applies small amounts of material. The SEA materials are new and as
a category require further testing in the laboratory and in clinical
trials before they can obviate the need for a separate etching step
using phosphoric acid.
5. Once the areas where tooth structure has been removed are restored
with composite material (or a material of choice) and light-cured, the
sealant layer is applied. The sealant layer is designed to fill in any
voids or gaps in the restorative material while acting as a sealant
over cleaned or untouched adjacent pits and fissures. The sealant
layer, as the restorative layer, does not have to be a light-cured
version of resin, and autocured material is equally, or perhaps more,
effective.
6. The rubber dam is removed, and occlusion is checked. Although an
unfilled sealant will be quickly ground into occlusion, if the
underlying composite is too high, it will result in discomfort for the
patient if the occlusal interference is not adjusted. It is not a problem
if this occlusal adjustment removes the sealant over part of the
composite, because the two layers will have bonded together
completely.

Recent work on PRRs and other minimally-invasive procedures has

been enlightening. In a systematic review of available evidence,
McComb
[19] reported generally favorable outcomes for the PRR, whereas the
evidence revealed ‘‘low effectiveness for ‘tunnel’ restorations.’’ Tunnel
restorations are also an attempt to conserve tooth structure, in this case,
for interproximal lesions, but the literature is equivocal, and the clinical
procedure is of questionable general use. A more realistic conservative
class II procedure is the conservative proximal slot preparation, which
McComb reports as having ‘‘supportive results’’ [19].
Feigal [20] reported that PRRs had a proven record but were
susceptible to failure as the overlying sealant failed. McCombe noted
that, ‘‘The weak
820 SIMONSEN

link in the latter [PRR] is the overlying fissure sealant, which requires
adequate ongoing maintenance’’ [19]. Generally, a properly placed type
3 PRR using a posterior composite as the restorative material and a
sealant
as the preventive component on top of the restorative material (placed
into unprepared but etched pits and fissures) will show wear of the
sealant layer first. Nevertheless, wear or loss of the sealant should not
necessarily constitute ‘‘failure’’ of the PRR. Although the sealant should
be replaced in the event of loss, as is true in any area where sealant is
applied and the caries susceptibility is significant, if there is no
immediate danger of caries from the loss, the restorative material used
should function adequately for many years before resurfacing may be
required.
Lyons [21] from the Ministry of Health in New Zealand reported that,
‘‘Preventive resin restorations should be placed to restore deep pits and
fissures with incipient caries or developmental defects in primary and
permanent teeth.’’ The PRR has become accepted on a global basis as
the technique of choice for minimally invasive treatment of incipient or
small carious lesions in pit and fissure surfaces.
The use of fluoride-releasing materials such as glass-ionomer cements
has been suggested and attempted over the years for sealant application
and in minimally-invasive procedures such as atraumatic restorative
treatment (ART). ART has been proposed as a minimal intervention
technique to manage dental caries. It is mainly performed in third-world
countries or areas where there may not be electricity or other staples of
optimal treatment on a regular basis. Glass-ionomer cements have been
used extensively in ART. The results generally cannot be compared with
the outcome of PRR or sealant treatment in the United States or Europe
where application conditions are generally ideal. A recent study in
Tunisia reported that less than half of the ART restorations survived 3
years, with slightly more than half of the glass-ionomer sealants
surviving after 3 years [22].
An extensive review of the literature in 1996 on glass-ionomer
sealants was not encouraging in terms of retention but somewhat more
positive for caries prevention. As of 1996, the published literature
indicated that
retention for resin-based sealants was better than for glass-ionomer
sealants, but the differences in caries prevention remained equivocal
[23]. A more recent clinical evaluation confirmed the previous review. It
reported that the retention rates of the glass-ionomer materials
(including one resin-modified glass-ionomer material) were low [24]. In
another study, the retention and the caries- preventive effect of a glass-
ionomer developed for fissure sealing (Fuji III) and a chemically-
polymerized, resin-based fissure sealant (Delton) were com- pared. After
3 years, the glass-ionomer sealant had poorer retention and less of a
caries-protective effect than the resin-based sealant [25].
Although the ART approach has been shown to be beneficial in
improving the oral health of many patients in developing countries [26],
I believe that ART should be more realistically termed a caries
control
PRRs AND SEALANTS IN LIGHT OF CURRENT
821
EVIDENCE

treatment (CCT). ART is supposedly atraumatic (without use of

anesthesia) because the caries is removed with a spoon excavator
(presumably until the patient winces); however, the lack of ‘‘trauma’’ is
inherently difficult to define and even harder to measure. Because ART
is not a definitive restorative treatment, the ‘‘A’’ and the ‘‘R’’ are, in my
opinion, misplaced terms. No attempt is made to remove all of the caries,
and glass-ionomer restorative material is then applied, sometimes with
finger pressure. Exactly how researchers have defined ‘‘success’’ for ART
varies considerably, and the process cannot be compared with how
researchers evaluate more conventional restorative procedures (such as
using United States Public Health Service criteria). Success in an ART
study can mean that most of the restorative material is still present
without attention to marginal degrada- tion or the color of the
restorative material being factored into the results. The results must be
evaluated in the context of the study criteria, and it is doubtful, in my
opinion, whether ART can be useful in most first-world countries except
in certain pockets of populations. Nevertheless, in countries where ART
has been tested, the adherents are enthusiastic about its effects on the
oral health of the patients treated. As a caries control technique, ART
appears to be a valuable tool in fighting caries in any area where the
disease is rampant.
Although sealants were a necessary step in the development of
minimally- invasive restorative procedures such as the PRR, they now
face some criticism from those who think of ‘‘hidden caries’’ as a new
phenomenon somehow associated with the increased use of fluoride.
The argument is that, in this modern age, the use of fluorides has
strengthened the enamel of many people to the point where enamel can
withstand the ravages of caries attacking the underlying dentin for some
time without collapsing (the cariogenic bacteria having entered through
an almost invisible pinpoint pit or fissure). As a result, it is argued that
placing a sealant is dangerous, because it could lead to progression of
the carious lesion under the sealant, which would block (because many
sealants are opaque) the view of the underlying lesion progressing.
Indeed, the theme of hidden caries is discussed in more detail elsewhere
in this issue. The concept of hidden caries is not a new phenomenon and
was noted in a book published in 1890 entitled, The Diseases of Children’s
Teeth, Their Prevention and Treatment. The author notes that, ‘‘it is not
uncommon to find, in preparing a cavity for filling, that a comparatively
small hole in the enamel leads down to a large unexpected, or at all
events previously unknown, excavation in the dentine’’ [27]. I have no
reason to believe that this is the first reference to hidden caries, but it
does document that hidden caries is not a recent phenomenon. To use
the ‘‘recent’’ development of hidden caries as a reason to question the
advisability of applying sealant as a preventive material is, in my
opinion, a fallacy.
A recent extensive review of the sealant literature [18] encompassing
almost 1500 references concluded that pit and fissure sealants are well
documented in terms of successful retention and caries prevention. In
822 SIMONSEN

addition, the effect of the application of sealant over carious lesions is

documented.

Summary

My task for this issue was to discuss pit and fissure sealants and the
P in light o current
RR f l hat both procedures are
thinking. It seems c ear
valid, acceptable,
t and recommendable treatmentsdone preventive and
the
other a combination of preventive and restorative treatment. Pit and
fissure sealant should be a treatment option provided to all children at
the age immediately after eruption of the posterior teeth, particularly but
not exclusively, the permanent teeth. Although there are some children
who will not benefit from sealants (those lucky few who will remain
caries- free throughout life), most others will benefit greatly from the
prevention of pit and fissure caries. This benefit is well-documented in
the peer- reviewed literature. The PRR is a minimally-invasive
procedure that should be the treatment of choice for small carious
lesions in posterior teeth. The Class I amalgam should not be placed as a
first-time restorative material to treat incipient or small carious lesions
under any circumstances. The amount of tooth structure removal
necessary for a class I Black preparation, which requires sufficient depth
of amalgam and extension for prevention, is so much greater than the
PRR approach that it renders the Class I amalgam an unacceptable
treatment when minimally-invasive options are available.

References

[1] Buonocore MG. A simple method of increasing the adhesion of acrylic filling
materials to enamel surfaces. J Dent Res 1955;34:849–53.
[2] Cueto EI, Buonocore MG. Adhesive sealing of pits and fissures for caries prevention. J
Dent Res 1965;44:137.
[3] Gwinnett AJ, Buonocore MG. Adhesives and caries prevention: a preliminary
report. Br Dent J 1965;119:77–80.
[4] Cueto EI, Buonocore MG. Sealing of pits and fissures with an adhesive resin: its use in
caries prevention. J Am Dent Assoc 1967;75:121–8.
[5] Ismail AI. Reactor paper: minimal intervention techniques for dental caries. J
Public Health Dent 1996;56:155–60.
[6] Cherry-Peppers G, Gift HC, Brunelle JA, et al. Sealant use and dental utilization in US
children. ASDC J Dent Child 1995;62:250–5.
[7] Gonzalez CD, Frazier PJ, LeMay W, et al. Sealant status and factors associated with
sealant presence among children in Milwaukee, WI. ASDC J Dent Child 1995;62:335–
41.
[8] Simonsen RJ. Retention and effectiveness of dental sealant after 15 years. J Am Dent
Assoc 1991;122:34–42.
[9] Zachrisson BU. Excellence in orthodontics. Interview by M.G. Choukroun and O.
Sorel. Orthod Fr 2000;71(4):317–24.
[10] Ulvestad H. A 24-month evaluation of fissure sealing with a diluted composite
material. Scand J Dent Res 1976;84(2):51–5.
[11] Simonsen RJ. New materials on the horizon. J Am Dent Assoc 1991;122:25–31.
 PRRs AND SEALANTS IN LIGHT OF CURRENT
EVIDENCE 823

[12] Simonsen RJ, Stallard RE. Sealant-restorations utilizing a diluted filled composite
resin: one year results. Quintessence Int 1977;8:77–84.
[13] Simonsen RJ. Preventive resin restorations (I). Quintessence Int 1978;9:69–76.
[14] Simonsen RJ. Preventive resin restorations (II). Quintessence Int 1978;9:95–102.
[15] Bowen RL. Dental filling material comprising vinyl silane treated fused silica and a
binder consisting of the reaction product of bisphenol and glycidyl acrylate. United
States patent no. 3,066,122; Nov 1962. Washington (DC): Commissioner of Patents &
Trademarks; 1962.
[16] Simonsen RJ. Preventive resin restorations: three-year results. J Am Dent Assoc
1980;100(4): 535–9.
[17] Simonsen RJ. Conservation of tooth structure in restorative dentistry. Quintessence Int
1985;16:15–24.
[18] Simonsen RJ. Pit and fissure sealant: review of the literature. Pediatr Dent 2002;24(5):
393–414.
[19] McComb D. Systematic review of conservative operative caries management
strategies. J Dent Educ 2001;65(10):1154–61.
[20] Feigal R. Sealants and preventive resin restorations: review of effectiveness and
clinical changes for improvement. Pediatr Dent 1998;20(2):85–92.
[21] Lyons K. Direct placement restorative materials for use in posterior teeth: the
current options. N Z Dent J 2003;99(1):10–5.
[22] Abid A, Chkir F, Ben Salem K, et al. Atraumatic restorative treatment and glass
ionomer sealants in Tunisian children: survival after 3 years. East Mediterr Health J
2002;8(2–3): 315–23.
[23] Simonsen RJ. Glass ionomer as a fissure sealantda critical review. J Public Health Dent
1996;56:146–9 [discussion: 161–3].
[24] Pereira AC, Pardi V, Mialhe FL, et al. A 3-year clinical evaluation of glass-ionomer
cements used as fissure sealants. Am J Dent 2003;16(1):23–7.
[25] Poulsen S, Beiruti N, Sadat N. A comparison of retention and the effect on caries of
fissure sealing with a glass-ionomer and a resin-based sealant. Community Dent Oral
Epidemiol 2001;29(4):298–301.
[26] Frencken JE, Holmgren CJ. ART: a minimal intervention approach to manage
dental caries. Dent Update 2004;31(5):295–8, 301.
[27] Denison Pedley R. The diseases of children’s teeth, their prevention and treatment.
Philadelphia: S.S. White Dental Manufacturing Company; 1890.

Litezatuce contrasting the use of composite resin sealants in the piwentive resin
restoration to the amalgam restoration is revived. In selected cases such as those invol
inng anleMor pits and fissures with minimal caries, sealants provide a valuable
tceatment alternative.
Preventive resin restorations
Edward J Switt, Jr., DMD
n describing cavity preparations for
I
smooth surface caries, G. V. Black
said that margins should be extended
into
self-cleaning areas to prevent recurrence of
decay. This doctrine of extension for pre-
vention has been broadened to include the
treatment of potentially cations pits and
fissures.' •3
In 1923, Hyatt° ^ introduced the still-
used technique of prophylactic odontot-
omy, including preparation and restora-
tion of caries-susceptible pits and fissures.
Another method of treatment, less frequent-
ly used today, involves eradicating fissures
by mechanical shaping and smoothing.
Because of preventive practices in
today's dentistry, such as using fluorides,
the inci- dence of caries has declined. This
has allowed for a conservative approach to
the concept of extension for prevention. De-
spite modifications in Black's original prin-
ciples, specifically an emphasis on preser-
vation of tooth structure, extension for
prevention is the basic principle of opera-
tive dentistry.'
Pit and fissure sealants
An alternative to mechanically treating
potentially carious pits and fissures is use
R E VI E W AR T IC LES
of acid-etched resin sealants. Studies have
proved the safety and efficacy of sealants,
but surveys still indicate that pit and fissure
sealants are underutilized.' '
Various reasons discouraging use of seal-
ants have been cited by practitioners."°
First, sealants have short longevity because
of poor retention. This is a valid concern as
retention is an important determinant of
sealant success. A sealant is effective only
if it remains adherent to the tooth.'
Contrary to the belief of many dentists,
several stud- ies have shown good rates of
retention.' '°''' In addition, retention is highly
dependent on a meticulous technique of
placement. 1 i 1 Second, sealants can “seal
in” caries. How- ever, this statement
contradicts many stud- ies showing that
when the sealant remains intact over a pit or
fissure, only a limited number of bacteria
remain viable. Further- more, those bacteria
appear to be incapable of causing
continued damage to the tooth.' '° '^ Third,
patients and insurance companies are
reluctant to pay for sealants. Unfortunately,
this is true in many cases. It is hoped that
this problem will decrease as both the
public and third-party carriers are informed
of cost-effectiveness and other benefits of
sealants.' Finally, some practi- tioners
believe that sealants are not effec-
tive in the prevention of caries. In a
survey of US dentists, sealants were rated
very low as an effective caries prevention
procedure.' However, studies have in fact
shown a
dramatic reduction of caries after sealant
use during periods of 1 to 7 years.'° i '
Preventive resin restoration
Sealants are often used as a preventive
mea- sure in treating noncarious pits and
fis- sures. In addition, sealants can be used
to treat pits and fissures that have minimal
or questionable caries.'^ Simonsen, who
terms this technique preventive resin
restoration, recommends it for restoring
carious lesions at the early stages with
removal of minimal tooth structure, while
simultaneously pro- tecting unprepared
areas from later caries attack.5,6,9 I }
The preferred material for most poste-
rior restorations remains amalgam, as amal-
gam has proved durable during years of
clinical experience. However, some draw-
backs to its use include ’ ’' :
—Amalgam preparations require remov-
al of a portion of healthy tooth structure.
Even small, conservative restorations can
significantly weaken the tooth.
—Secondary caries may occur at the
JADA, Vol. 114, June 1987 ■ 819
REVIEW ARTICLES

margins of a restoration and in unprepared ed, the first and most important is the each, standard acid-etching procedures are
used. pits and fissures. requirement for absolute, meticulous adher- All unprepared pits and fissures, minimal
—Marginal leakage and breakdown of ence to the principles of acid-etch tech- exploratory preparations, and small carious
amalgam can contribute to recurrent caries. nique (isolation from moisture). This can lesions are restored with a pit and fissure sealant.
—Amalgam is not an esthetically pleas- create a more time-consuming clinical Simonsen refers to this as the type I preventive
ing material. procedure. Also, long-term wear and resin restoration.°'
reten- The preventive resin restoration can elim- tion, as compared with amalgam If the preparation must be made slightly
restora- larger, a wear-resistant posterior composite
inate these problems in certain cases. A tions, have not been proved.5 " '" '° resin is indicated for its restoration. After
conservative method of preparation is used, application of a liner (on exposed dentin) and
bonding agent, the filled resin is gently placed.
preserving sound tooth structure. Resin Clinical technique
Using a
restores the prepared area, with sealant brush or plastic instrument, the resin is extended
placed over adjacent, unprepared fissures. Several options in the preventive resin restora- into adjacent fissures to create a filled sealant.
Any caries-susceptible areas on the tooth, which
are not directly adjacent to the preparation, are
Preventive resin zastarations aze costraindicatsd treated with a conventional pit and fissure
sealant. In Simonsen’s classification, this method
is called the type 2."
Differing somewhat is the type 3 technique in
which the filled resin is used only to restore the
prepared cavity. Adjacent fissures are covered
with a pit and fissure sealant.°^ If light-cured
materials are used, they can be cured simulta-
The result is a restoration that helps pre- tion technique are feasible, depending neously. °° Alternatively, the posterior composite
mainly vent secondary caries and is more attractive on vhe size of the preparation resin may be placed and cured first, then covered,
required. Regard-
than amalgam.4,5, l8 less, the procedure involves a series of basic along with adjacent fissures, with a sealant.'•"'
steps.
Several indications for the preventive The tooth is first examined radiographically for Final Iy, the rubber dam is removed and the
resin restoration included ° I°'°°: question- any evidence of interproximal orocclusal caries. occlusion is checked carefully for prematurities
able caries, or an explorer catch in a pit or Then, the occlusal surface is carefully examined K hlgh Spots. This is especially inn portant if a
fissure; minimal, shallow pit and fissure with a sharp explorer. The practitioner must filled material is used, for it will not wear as
caries; deep pits and fissures that could check for explorer catch and resistance to remov- quickly as the unfilled type. Any necessary
al, soft or opaque areas, or discontinuity of the adjustment may be done, using white stones or
inhibit complete penetration of sealant enamel surface. Each of these factors can indi- finishing burs.'•'°°'°'
material or could be carious at their bases; cate the presence and degree of caries.^
deep pits and fissures with extensive sup- Local anesthesia is administered to the
patient, plemental fissuring and small areas of if necessary (when caries is tiesults of research
present). Next, occlu-
decay; an opaque, chalky appearance along sion is checked and marked with articulating The preventive resin restoration was first de-
pits and fissures that could indicate incip- paper. The tooth is isolated with cotton rolls or scribed in the literature in 1977-78." Earlier
ient caries. rubber dam; the latter is preferable. Regardless research on the use ot dilute composite resin as a
Preventive resin restorations are contra- of which method is used, adequate isolation is fissure sealant laid the groundwork for Simon-
indicated for large, deep, or multisurface extremely important.^''•"•'"' A small round bur sen’s preventive restoration technique.°''°'
carious lesions.5 °° Therefore, these (no. / to 1) is used at high or low speed to make a Later clinical studies of up to 7 years have
restora- minimal exploratory preparation into any deep shown high rates of retention and caries preven-
tions are not intended as a substitute for pits and fissures.''^'^'•''" If caries is encountered, tion.•'"'"' '' ^'" Most failures seem to be related
io
amalgam, but as an alternative treatment better access may be gained with a pear-shaped improper techniques, such as lack of adequate
in selected cases. bur (no. 329 or 380).'° This preparation exposes moisture control. '•
caries. No attempt is made to create retention, In vitro research has been performed on the
Advantages and Misadyantages ti On . S,9, IO
A few disadvantages are associated with the preventive resin restoration. As report-
The preventive resin restoration has
several advantages. As cited earlier, less
tooth struc- ture is removed than with a
conventional preparation, leaving a much
stronger tooth.S ° This isin contrast to the
extension for prevention method by which
removal of sound tooth structure to
prevent recur- rent decay simultaneously
weakens the tooth.'^ 2' As mentioned, the
sealed restora- tion can eliminate recurrent
caries. As less
mechanical preparation is required, the
patient suffers less discomfort and usually
does not require anesthesia. Finally, the
restoration may be added to, replaced, or
repaired without further tooth prepara-
 remove slightly undermined enamel, or extend calcium hydroxide or glass ionomer, should be unfilled. '"''^''• An 18-month clinical study com-
placed.°°'"' In some cases, a large amount of car- paring preventive resin restorations with amal-
ies may be discovered, and then a conventional gam restorations in contralateral teeth found
into sound pits and fissures.'•'°' If the
prepara-
restorations. This research has shown that the
tion extends into dent in, it must be checked
care-
preventive resin restoration possesses an inti-
fully to detect any caries that spreads laterally
at
mate enamel-resin interface and provides a (amalgam) restoration can be initiated. that the marginal integrity of the resin restora-
good the dentinoenamel junction. Also, a liner, Depending on the extent of the preparation tions was better. This same study also rated the
either required to examine for and remove caries, a wear of the composite/sealant restorations as
seal, regardless ot whether the resin is filled or tooth may be restored in one of three ways. For excellent.'°

820 ■ JADA, Vol. 114, June 1987


The modern decline in caries incidence has
caused many dentists to reconsider the tra-
ditional methods of preventing recurrent
caries. More emphasis is being placed on
the preservation of sound, healthy tooth
structure. The proved success of pit and
fissure sealants has led to the development
of a relatively new restorative technique,
the preventive resin restoration. In selected
cases, this technique can be effective, in
terms of both caries prevention and preser-
vation of tooth structure. As resin materials
continue to improve and the caries rate
continues to decline, the preventive resin
restoration should become a fundamental
procedure of operative dentistry.
jj
Dr. Edward J Swift. J , is clinical instructor, depart-
ment of operative dentistry, College of Dentistry, Uni-
versity of Iowa, Iowa City, 5?242. Address requests for
reprints to the author.
1. Sturdevant, C. M. The art and science of operative
dentistry, ed 2. St. Louis, C. V. Mosby Co, 1985, pp 2,
86.
2. Gibson, G.B., and Richardson, A.S. Sticky fissure
management. Can Deni Assoc J 46(4):256-258, 1980.
3. Simonsen, RU Preventive aspects of clinical resin
technology. Dent Clin North Am 25(2):291-306, 1981.
4. Elderton, R.J. Management of early dental caries
in fissures with fissure sealant. Br Dent J 158(7):254-258,
1985.
5. Simonsen, R.J. Preventive resin restorations.
Quintessence Int 9(1):69-76, 1978.
6. Simonsen, R-J Preventive resin restorations: three-
year results. J ADA 100(4):535-539, 1980.
7. Gift, H.C., and Frew, R.A. Sealants: changing
patterns. JADA 1I2(3):591, 1986.
8. Sealants need more promotion, study says. Gen
Dent 34(2):86, 1986.
9. Simonsen, R.J. Potential use of pit and fissure
sealants in innovative ways: a review. J Public Health
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10. Ripa, L.W. The current status of pit and fissure
sealants: a review. Can Dent Assoc J 51(5):367-375,
1986.
11. Houpt, M., and Shey, Z. The effectiveness of a
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106, t9g3.
12. Handelman, S.L.; Washburn, F.; and Wopperer,
P. Two-year report of sealant etlect on bacteria in dental
caries J ADA 93( 11):967-970, 1976.
13. Mertz-Fairhurst, E.J., and others. Clinical prog-
ress of sealed and unsealed caries: depth changes and
bacterial counts. ) Prosthet Dent 42(5):521 -526, 1979.
14. Mertz-Fairhurst, E J . and others. Clinical prog-
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graphs and clinical observations. J Prosthet Dent
42(6):633-637, 1979.
15. Mertz-Fairhurst, E.J.; Schuster, G.S.; and Fair-
hurst, C.W. Arresting caries by sealants: results of a
clinical study. JADA 112(2):194-197, 1986.
16. Raadal, M. Follow-up study of sealing and fil-
ling with composite resins in the prevention of
occlusal caries. Community Dent Oral Epidemiol
6(4):176-180, 1978.
17. Simonsen, R.)., and Jensen, M.E. Preventive
resin restorations utilizing diluted filled composite res-
ins: 30-month resul ts. J Dent Res 58 (special issue
A):261, abstract no. 676, 1979.
18. Houpt, M., and Shey, Z. Occlusal restoration
using fissure sealant instead of extension for preven-
tEVIEW ARTICLES
tion. Quintessence Int 16(7):489-492, 1985.
19. Hicks, M.J. Preventive resin restorations: etching
patterns, resin tag morphology and the enamel-resin
interface. ASDC J Dent Child 51(2):116-123, 1984.
20. Henderson, H.Z., and Setcos, J.C. The sealed
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tion. ASDC J Dent Child 51(4):270-273, 1984.
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?3. Simonsen, R.J. Conservauon of tooth structure
in restorative dentistry. Quintessence Int 16(I ):15-24,
1985.
24. Ulvestad, H. A 24-month evaluation ot fissure
sealing with a diluted composite material. Scand J Dent
Res 84(2):51 -55, 1976.
25. Ulvestad, H. Evaluation of fissure sealing with a
diluted composite sealant and an UV -polymerized
sealant atter 56 months’ observation. Scand J Dent Res
84(6):401 -403, 1976.
26. Simonsen, R J . and Landy, N.A. Preventive
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results. ) Dent Res (Special Issue):1 75, abstract no. 39,
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27. Stanley, R.T., and others. A clinical report on
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28. Raadal, M. Microleakage around preventive com-
posite fillings in occlusal fissures. Scand J Dent Res
86(6):496-499. 1978.
29. Raadal, M. Microleakage around preventive com-
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87t5):390-394, 1979.
30. Azhdari, S.; Sveen, O. B.; and Buonocore, M.B.
Evaluation of a restorative preventive technique for
localized occlusal caries. J Dent Res 58 (Special Issue
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Swift : PREVENTIVE RESIN RESTORATIONS ■ 821