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TYPE Mini Review

PUBLISHED 17 April 2023
DOI 10.3389/froh.2023.1180405

A concise review of dental

sealants in caries management
EDITED BY
May Lei Mei,
Toby Cheuk-Hang Ng, Chun-Hung Chu and Ollie Yiru Yu*
University of Otago, New Zealand
Faculty of Dentistry, The University of Hong Kong, Hong Kong SAR, China
REVIEWED BY
Bhojraj Nandlal,
JSS Dental College and Hospital, India This concise review provides an update of the use of dental sealants. Dental
*CORRESPONDENCE sealants protect a tooth from caries development by providing a physical barrier
Ollie Yiru Yu to microorganism colonisation and creating a favorable environment for patients
ollieyu@hku.hk
to clean. Some sealants release fluoride ions to promote remineralization.
SPECIALTY SECTION
Dental sealants can be applied on pits and fissures of primary and permanent
This article was submitted to Preventive
teeth to prevent and arrest early enamel caries. They are effective in caries
Dentistry, a section of the journal Frontiers in
Oral Health prevention. The preventive fraction of resin sealant is up to 61% after 5 years.
Dental sealants can be classified as resin, glass ionomer and hybrid (compomer
RECEIVED 06 March 2023
ACCEPTED 29 March 2023 or giomer) according to the material. Recent studies from 2012 to 2022 showed
PUBLISHED 17 April 2023 resin sealant has a high retention rate of up to 80% after 2 years, whereas glass
CITATION ionomer sealants is 44%. Chemical etching with 37% phosphoric acid is the
Ng TC-H, Chu C-H and Yu OY (2023) A concise standard of care, whereas laser or air-abrasion cannot does not increase the
review of dental sealants in caries management. sealant retention rate. Moist control is critical and studies found the use of
Front. Oral. Health 4:1180405. rubber dam and cotton rolls had similar success for sealant retention. The
doi: 10.3389/froh.2023.1180405
longevity of dental sealant is also associated with clinical operative factors,
COPYRIGHT
including approaches of moisture control, enamel pretreatment, selection of
© 2023 Ng, Chu and Yu. This is an open-access
article distributed under the terms of the dental adhesive, and time of acid etching.
Creative Commons Attribution License (CC BY).
The use, distribution or reproduction in other
KEYWORDS
forums is permitted, provided the original
author(s) and the copyright owner(s) are dental sealant, dental caries, caries management, cariology, preventive dentistry, oral
credited and that the original publication in this health
journal is cited, in accordance with accepted
academic practice. No use, distribution or
reproduction is permitted which does not
comply with these terms. 1. Introduction
For Dental caries, commonly known as tooth decay, is a highly prevalent oral disease
around the world. More than 2.4 billion people are suffering from permanent teeth caries
while 520 million children are affected by primary teeth caries (1). Untreated dental
caries gradually extends and irritate the dental pulp, leading to the destruction of the
tooth structure, excruciating pain, and eventually tooth extraction (2). Dental caries
degrades the quality of life of the patients (3). It can also lead to lower self-esteem (4)
and depression (5). Pits and fissure areas in the tooth surface are highly susceptible to
dental caries. Dental caries was the demineralization of dental hard tissue caused by acid
produced by the fermentation of carbohydrates by cariogenic bacteria in the dental plaque
biofilm (6). Because of the anatomical structure, the dental plaque biofilm in the fissure is
difficult, if not impossible, to remove through daily oral hygiene practice. The caries risk
is higher in teeth with deep fissures (7, 8). An observational study found caries were
located in the occlusal fissure areas in 79% of the decayed molars (9).
Because of the susceptibility of pit and fissure areas to dental caries, oral care providers
have been trying to eliminate fissures to control caries. The initial approach to eliminate
fissures was invasive. Hyatt suggested prophylactic odontotomy in 1923, which was an
invasive dental procedure to remove deep fissures with a dental bur and place a filling to
prevent caries (10). Three decades later in 1955, Buonocore proposed a fissure sealing
procedure with the 85% phosphoric acid etching of enamel followed by a resin material
coverage on the fissure area (11). This technique was a foundation for the further

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development of fissure sealing using different dental materials. (TEGDMA) are in alternative use (18). Resin sealant may also
Cueto suggested using methyl cyanoacrylate to seal pits and contain filler, fluoride particles or photoinitiations.
fissures in 1965 (12). Later, Buonocore successfully applied light-
cure dental sealant incorporated with Bisphenol A-glycidyl 3.1.1. Auto-cure resin sealant or light-cure resin
methacrylate (Bis-GMA) in 1970 (13). In the following year, the sealant
Council on Dental Materials Devices and Council on Dental Based on the ways of polymerization, resin sealant could be further
Therapeutics of the American Dental Association recognized the classified as self-cure or light-cured resin sealant. Resin sealant sets after
use of dental sealant (14). The first glass ionomer sealant undergoing polymerisation of monomers. The polymerisation occurs
appeared in the mid-1970s (15). in two ways, auto-polymerisation or polymerisation under an
As a common preventive strategy for dental caries, the external light source. The setting of self-cured resin sealant is an
understanding and the application of dental sealant has been shifting auto-polymerisation reaction initiated by chemical reactions. The
in accordance with the contemporary paradigm of caries chemical reactions of auto-polymerisation process are initiated by
management, which placed prevention as a priority (16). The clinical the free radicals produced by chemical reactions of tertiary amine
application of dental sealant has been broadening when compared to and benzoyl peroxide (19). No external light source is required.
the past. Dental sealant was majorly used in the pits and fissure area Light-cured resin sealant requires an external light source to imitate
of the occlusal surface in the posterior area in the past. It is now a the polymerisation. Photo-initiators in the resin sealant absorb light
common preventive measure to manage dental caries in the occlusal radiation, dissociating into free radicals, and start the polymerisation
or approximal surfaces of the anterior or posterior teeth in primary process (20). The external light source could be ultraviolet or visible
or permanent dentition. It can also be used on exposed root surfaces light. However, UV can cause health hazards (21) and is seldom
to prevent root caries. In addition, with the development of dental used for resin sealant now (22). Visible light is commonly used for
material sciences, more materials are available as dental sealants. the polymerization of resin sealant (23).
Therefore, the objective of this review is to overview and update the
knowledge of dental sealants in the aspect of their classification, the 3.1.2. Fluoride-releasing resin sealant or non-
mechanism in caries prevention, clinical indications, effectiveness in fluoride releasing resin sealant
caries control, clinical longevity and factors affecting the clinical Resin sealant can also be classified by its fluoride-releasing
outcomes in the 2012–2022. ability. Fluoride particles such as sodium fluoride or fluoride-
releasing glass filler, are incorporated into the material in
fluoride-releasing resin sealant (24). It provides an additional way
to achieve caries prevention.
2. Literature search
Keywords ((fissure sealant) OR (dental sealant)) AND 3.1.3. Filled resin sealant or unfilled resin sealant
(dental caries) are used to search for articles in the PubMed Based on the filler content, we can also classify the resin sealant
and Scopus databases. Articles published from 2012 to 2022 as filled or unfilled resin sealant. The wear resistance of filled resin
were selected. After duplicate removal, 886 articles were sealant is higher than unfilled resin sealant (25). However, the
identified. The titles and abstracts of the identified article were viscosity of sealant also increases with the filler added, therefore
screened. Finally, we included 175 articles on dental sealants leading to a lower ability to penetrate fissures and pits (26).
and caries for this review. Among the included articles, 27
articles were randomized clinical trials comparing caries 3.1.4. Hydrophobic resin sealant or hydrophilic
prevention and/or retention rate of dental sealant. resin sealant
Based on the sensitivity to moisture, resin sealant can be
classified as hydrophobic or hydrophilic resin sealant.
Conventional resin sealant is hydrophobic. Recently, a new
3. Classification of dental sealant by generation of hydrophilic resin sealant has been developed by
material adding multifunctional acrylate monomers with a formulation
considering the hydrophilic-hydrophobic balance (27).
Dental sealants can be broadly classified into three categories Hydrophilic resin sealant is believed to be able to overcome the
based on the components—resin sealant, glass ionomer sealant moisture challenge during the operative process of sealant
and hybrid sealant. application.

3.1. Resin sealant 3.2. Glass ionomer sealant

Resin sealant contains an organic resin-based oligomer matrix Two types of glass ionomer sealants are available, conventional
(17). Bis-GMA is the most common monomer for the matrix of glass ionomer sealant and resin-modified glass ionomer sealant.
resin sealant. Other resin monomers such as Urethane- Conventional glass ionomer sealant is comprised of powders of
dimethacrylate (UDMA) and Triethylene glycol dimethacrylate fluoroaluminosilicate glass and liquids containing polyacrylic

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acid, tartaric acid and water (28). It sets with the acid-base plaque retentive occlusal surface into a smoother surface which
reactions of powder and liquid when mixed (29). Resin-modified makes the surface easier to clean (37).
glass ionomer sealant is made by introducing resin-based
monomers such as 2-hydroxyethylmethacrylate (HEMA) or
UDMA into the conventional glass ionomer (30). The physical 4.3. Ion release
properties of resin-modified glass ionomer sealant are improved
compared to conventional glass ionomer sealant (31). The resin- Different types of dental sealants can release ions which can
modified glass ionomer sealant set with the polymerisation of prevent and arrest caries. Glass ionomer sealants, hybrid sealants
resin-based monomers followed by acid-base reactions of powder and some resin sealants are fluoride-releasing. Fluoride ion
and liquid (32). reduces demineralization, promotes remineralization (38) and
inhibits the growth of cariogenic bacteria (39). Fluoride-releasing
sealant can prevent and stop the progression of caries of the
3.3. Hybrid sealant sealed tooth (40). It can also offer protection to the adjacent
tooth (41). Some giomer sealants release antimicrobial borate and
Hybrid Sealants include compomer sealant and giomer strontium that inhibit bacterial growth (42). Borate and
sealant (33). Compomer is also known as polyacid-modified strontium ions, together with sodium ions released by giomer,
composite resin. It contains non-reactive inorganic filler could be a buffer to lactic acid (43).
particles, reactive silicate glass particles, a polyacid-modified
monomer and a photo-initiator (31). Giomer is comprised of
pre-reacted glass ionomer (PRG) filler and resin-based
5. Effects of dental sealant in
monomer matrix (34). Hybrid Sealants are relatively new and
preventing and arresting caries in the
not widely used.
past 10 years
Dental sealants can also be classified with colors. Clear, white,
and pink are three colors that can be commonly seen for dental
Studies published in the recent ten years (2012–2022) support
sealant. Clear dental sealant allows dentists to see through so that
dental sealant as an effective means of preventing and arresting
the lesion underneath could be better monitored (35). However,
caries (Table 1). Because of the heterogeneity of the included
clear sealant itself is more difficult to see, hence potentially
studies, we did not perform a meta-analysis in this review.
leading to a bias repair decision (35).
Table 1 shows the caries incidence of different dental sealants.
With the results of the studies that have blank control groups,
we summarize the preventive fractions are 92% for both resin
4. Mechanisms of dental sealant in sealant and glass ionomer sealant at a 6-month follow-up (52);
preventing and arresting caries 64% - 88% for resin sealant, and 88% for glass ionomer sealant
at an 18-month follow-up (68); 61% for resin sealant and 35%
Placing dental sealant is an effective approach to preventing for glass ionomer at a 60-month follow-up (56). Results of
and arresting caries. Possible mechanisms include the physical hybrid sealant were limited in the literature.
barrier created by the sealant, ease of cleaning for the patient,
and release of ions that favours remineralisation of the tooth.
6. Longevity of dental sealant
4.1. Physical barrier The caries preventive effect of dental sealant largely relies on
the retention of the sealant. Table 1 shows the retention rates of
Dental sealant covers the fissures and provides a physical dental sealants published in the past ten years (2012–2022). For
barrier. The cariogenic bacteria are difficult to enter and resin sealant, the retention rate ranges from 11% to 89% at a 6-
colonize in the fissure area with the physical barrier. This month follow-up (40, 52, 61, 62); from 18 to 88% at a 12-month
barrier also prevents food debris from getting into fissures follow-up (26, 45, 47, 49–51, 55, 58–60, 65, 67); from 24% to
which blocks the nutrition intake and inhibits the growth of 70% at an 18-month follow-up (54, 57, 68); from 21% to 80% at
dental biofilm (22). a 24-month follow-up (44, 46, 48, 63, 64, 66). Studies with
longer follow-up periods were limited. For glass ionomer sealant,
the retention rate ranges from 49% to 63% at a 6-month follow-
4.2. Ease of cleaning up (40, 52, 61); from 21% to 78% at a 12-month follow-up (47,
49, 50, 59, 60); and from 14 to 44% at a 24-month follow-up
Dental sealant can improve the oral hygiene of patients. (44, 46, 48, 64, 66). Studies in other follow-up periods were
Fissures can be deep and narrow. It is difficult or impossible for limited. For hybrid sealant, the retention rates range from 8% to
toothbrush bristles to get into the fissures and clean the area 26% at a 12-month follow-up (58, 65, 67). Studies with longer
(36). Applying dental sealant can seal the fissures. This turns a follow-up periods were limited.

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TABLE 1 Summary of randomized clinical trial published from 2012 to 2022.

Author (Year) [Ref] Duration Number and age of the Participants Intervention group Caries Sealant
(month) (Teeth) (final sample size) incidence retention
rate
Antonson et al. (2012) (44) 24 39 children aged 5–9 (78 teeth) Gp1: Resin sealant (27) N/A Gp1:41%
Gp2: Glass ionomer sealant (27) Gp2:44%
Bhatia et al. (2012) (45) 12 17 children aged 6–8 (68 teeth) Gp1: Hydrophilic resin sealant (34) N/A Gp1:24%
Gp2: Hydrophobic resin sealant (34) Gp2:18%*
Ulusu et al. (2012) (46) 24 173 children aged 7–15 (346 teeth) Gp1: Glass ionomer sealant (139) Gp1:3% Gp1:14%
Gp2: Resin Sealant (137) Gp2:5% Gp2:21%*
Bhat et al. (2013) (47) 12 80 children aged 6–9 (320 teeth) Gp1: Resin sealant with bond (76) G1:3% Gp1:82%
Gp2: Resin sealant (76) Gp2:3% Gp2:72%
Gp3: Hydrophilic resin sealant (76) Gp3:3% Gp3:80%
Gp4: Glass ionomer sealant (76) Gp4:7% Gp4:21%
*Gp1/2/3 > 4
Chen and Liu (2013) (48) 24 61 children aged 6–9 (158 teeth) Gp1: Glass ionomer sealant (75) Gp1:8% Gp1:36%
Gp2: Resin sealant (75) Gp2:8% Gp2:72%*
Kumaran (2013) (49) 12 40 children aged 7–10 (160 teeth) Gp1: Filled resin sealant 1 (38) N/A Gp1:66%
Gp2: Unfilled resin sealant (38) Gp2:42%
Gp3: Filled resin sealant 2 (38) Gp3:29%
Gp4: Glass ionomer sealant (38) Gp4:32%
*Gp1 > 2/3/4
Hasanuddin et al. (2014) (50) 12 80 children aged 7–10 (160 teeth) Gp1: Resin sealant (80) Gp1:0% Gp1:68%
Gp2: Glass ionomer sealant (80) Gp2:0% Gp2:24%*
Khatri et al. (2015) (51) 12 34 children aged 6–9 (68 teeth) Gp1: Hydrophilic resin sealant (32) Gp1:6% Gp1:72%
Gp2: Resin sealant (32) Gp2:16% Gp2:50%*
Reddy et al. (2015) (26) 12 56 children aged 6–9 (224 teeth) Gp1: Filled resin sealant (112) N/A Gp1:54%
Gp2: Unfilled resin sealant (112) Gp2:64%
Gonçalves et al. (2016) (52) 6 31 children aged 6–8 (114 teeth) Gp1: Resin-modified glass ionomer Gp1:3% Gp1:52%
sealant (33)
Gp2: Resin sealant (35) Gp2:3% Gp2:89%
Gp3: No sealant (28) Gp3:36% Gp3: N/A
*Gp1/2 > 3 *Gp2 > 1
Haznedaroğlu et al. (2016) (53) 48 40 children aged 7–10 (160 teeth) Gp1: Glass ionomer sealant (40) Gp1:10% Gp1:8%
Gp2: Resin sealant (56) Gp2:21% Gp2:39%*
Al-Jobair et al. (2017) (54) 18 42 children aged 6–9 (168 teeth) Gp1: Glass ionomer sealant (70) Gp1:31% Gp1:26%
Gp2: Resin sealant (70) Gp2:27% Gp2:33%
Askarizadeh et al. (2017) (55) 12 23 children aged 6–9 (92 teeth) Gp1: Resin sealant (40) Gp1:3% Gp1:63%
Gp2: Hydrophilic resin sealant (40) Gp2:8% Gp2:60%
Liu et al. (2018) (56) 60 419 children aged 7–9 (664 teeth) Gp1: Resin sealant (172) Gp1:13% N/A
Gp2: Glass ionomer sealant (178) Gp2:23%
Gp3: No sealant (165) Gp3:35%
*Gp1 > 2>3
Ntaoutidou et al. (2018) (57) 18 81 children aged 6–12 (218 teeth) Gp1: Giomer sealant (87) Gp1:15 % Gp1:7%
Gp2: Resin sealant (89) Gp2: 6%* Gp2:70%*
Siripokkapat et al. (2018) (58) 12 140 children aged 2.5–5 (280 teeth) Gp1: Resin sealant (116) Gp1:8% Gp1:72%
Gp2: Giomer sealant (116) Gp2:20%* Gp2:15%*
Alsabek et al. (2019) (40) 6 40 children aged 6–9 (80 teeth) Gp1: Hydrophilic resin sealant (40) N/A Gp1:85%
Gp2: Glass ionomer sealant (40) Gp2:63%*
Mathew et al. (2019) (59) 12 50 children aged 6–8 (100 teeth) Gp1: Resin-modified glass ionomer Gp1:2% Gp1:78%
sealant (50)
Gp2: Resin sealant (50) Gp2:0% Gp2:88%
Prathibha et al. (2019) (60) 12 120 children aged 7–9 (240 teeth) Gp1: Glass ionomer sealant (111) Gp1:9% Gp1:51%
Gp2: Resin sealant (111) Gp2:5% Gp2:76%*
Jaafar et al. (2020) (61) 6 45 children aged 8–12 (90 teeth) Gp1: Resin sealant (45) N/A Gp1:76%
Gp2: Glass ionomer sealant (45) Gp2:49%*
Mohapatra et al. (2020) (62) 6 30 children aged 12–15 (120 teeth) Gp1: Resin sealant (44) N/A Gp1:23%
Gp2: Hydrophilic resin sealant (44) Gp2:11%
Beresescu et al. (2022) (63) 24 28 children age 6–8 (112 teeth) Gp1: Hydrophilic resin sealant (56) Gp1:9% Gp1:79%
Gp2: Resin sealant (56) Gp2:5% Gp2:80%
Haricharan et al. (2022) (64) 24 180 children aged 6–12 (360 teeth) Gp1: Resin sealant (180) Gp1:7% Gp1:39%
Gp2: Glass ionomer sealant (180) Gp2:11% Gp2:32%
(continued)

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TABLE 1 Continued

Author (Year) [Ref] Duration Number and age of the Participants Intervention group Caries Sealant
(month) (Teeth) (final sample size) incidence retention
rate
Özgür et al. (2022) (65) 12 57 children aged 6–12 (136 teeth) Gp1: Resin sealant (50) Gp1:0% Gp1:68%
Gp2: Giomer sealant (50) Gp2:0% Gp2:8%*
Reic et al. (2022) (66) 24 80 children aged 6–13 (253 teeth) Gp1: Glass ionomer sealant (51) Gp1:27% Gp1:19%
Gp2: Filled resin sealant 1 (66) Gp2:11% Gp2:46%
Gp3: Unfilled resin sealant (58) Gp3:24% Gp3:21%
Gp4: Filled resin sealant 2 (58) Gp4:19% Gp4:47%
*Gp2 > 1/3/4 *Gp2/4 > 1/3
Singh et al. (2022) (67) 12 45 children aged 3–5 (180 teeth) Gp1: Giomer sealant (90) Gp1:14% Gp1:26%
Gp2: Hydrophilic resin sealant (90) Gp2:15% Gp2:76%*
Uzel et al. (2022) (68) 18 50 children aged 7–12 (200 teeth) Gp1: No sealant (35) Gp1:26% Gp1:N/A
Gp2: Resin sealant 1 (32) Gp2:9% Gp2:52%
Gp3: Resin sealant 2 (33) Gp3:3% Gp3:24%
Gp4: Glass ionomer sealant (33) Gp4:3% Gp4:18%
*Gp3/4 > 1 *Gp1 > 2/3

*Statistically significant.

7. Indications for dental sealant randomized clinical trial reported that non-sealed molars exhibited
placement based on the evidence a caries incidence of 98.9% while it was only 25.7% for the sealed
molars (73). A systematic review showed that the caries risk of
7.1. Caries risk of the patient sound teeth sealed with resin sealant occlusally is 76% less within
24 to 48 months follow up, and 85% less in 84 months follow up
Dental sealant is indicated for patients with high caries risk. The compared to no treatment (74). Dental sealant is effective in
effectiveness of dental sealant was proved to be higher in high arresting non-cavitated caries (40, 61). A systematic review showed
caries risk patients when compared with low caries risk patients that the chance of arresting or reversing non-cavitated occlusal
(37, 69). The benefits of dental sealant exceed the cost when caries with dental sealants is 2–3 times higher when compared
children with high caries risk were targeted (70). The cost- with no treatment (75). A clinical study over 44 months suggests
effectiveness of dental sealants is higher in patients with high that caries without frank cavitation can be arrested with dental
caries risk can be concluded. sealant (35). Dental sealant was also shown to arrest non-cavitated
dentinal occlusal caries 36 months after placement (76). In
addition, dental sealants placed on sound surfaces and carious
surfaces showed similar survival rates (77). Therefore, dental
7.2. Types of the dentitions
sealant is effective in arresting non-cavitated caries.
The effectiveness of dental sealant in arresting cavitated caries is
Dental sealant is suggested for permanent teeth. A systematic
controversial. A clinical study showed that caries progression was
review found that resin sealants placed on occlusal surfaces of
rarely detected for initial caries (ICDAS 2) to moderate caries
permanent molars could reduce caries for up to 4 years when
(ICDAS 4) sealed with resin dental sealant at the 24-month
compared to no treatment (22). Another systematic review and
follow-up (78). Dental sealant was found to be effective in
meta-analysis also found that resin sealant reduced caries
arresting ICDAS 3 micro-cavitated caries in permanent molars
incidence in permanent teeth at a follow-up period of up to 4
after a 2-year follow-up (79). However, another study found that
years (71). Dental sealant is suggested for primary teeth. A
dental sealant could arrest non-cavitated caries but not micro-
randomized clinical trial shows that resin sealant can arrest
cavitated caries (ICDAS 3) (80).
dentinal caries in primary teeth (72). A systematic review
concluded dental sealant had caries preventive effects in primary
teeth when compared to no treatment with low-certainty
evidence (36). In addition, it is a cost-effective approach to 7.4. Types of tooth surfaces
applying dental sealant in primary dentition (69).
A dental sealant can be applied on occlusal fissure surfaces. The
effectiveness of dental sealant in preventing dental caries in occlusal
7.3. Caries status of the tooth surfaces has been approved in a number of studies (22). Dental
sealant could also be applied on axial smooth surfaces. The
Dental sealant is effective in preventing caries on sound tooth application of dental sealant in sound or carious smooth surfaces
surfaces. Studies supported the application of dental sealant in is also supported by recent studies. A 3.5-year study on children
preventing caries on sound tooth surfaces (22, 71). A 3-year found out dental sealant applied on sound mesial smooth surfaces

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of first permanent molars can prevent distal caries on primary isolation for resin dental sealant and followed for 12 months
second molars (81). Dental sealants can also arrest non-cavitated after placement (90). The result was not statistically significant,
and micro-cavitated caries on proximal surfaces (82, 83). indicating the cotton and Isolite system are comparable in
placing dental sealant. A randomized clinical trial compared
Isolite system, cotton roll and rubber dam at the same time (91).
7.5. Eruption status of the tooth The result agreed with the above two studies. There was no
statistically significant difference between these three strategies.
Dental sealant can be applied on fully erupted or partially However, most patients preferred cotton roll isolation and most
erupted molars. However, the retention rate of the sealant in the patients were less likely to have rubber dam as isolation again (92).
partially erupted molars is lower due to saliva contamination and
the difficulty in moisture control (44). A randomized 24-month
clinical trial revealed that the retention of dental sealants is 8.2. Tooth surface preparation
significantly related to the occlusal eruption stage (84). In this
study, researchers found that the retention rate of dental sealants Tooth surfaces cleaned with pumice and prepared with 37%
placed on partially erupted teeth was lower than on fully erupted phosphoric acid for 30 s are suggested.
teeth. If a partially erupted molar is to be sealed, glass ionomer
sealant is a better choice than resin sealant. 8.2.1. Surface cleaning
Cleaning the tooth surface is required before applying dental
sealant. It is because tooth surfaces are covered by salivary
7.6. Presence of dental fluorosis pellicles and products of carbohydrate metabolism which inhibit
the penetration of dental sealant into the pits and fissure area
Dental sealant can be applied on teeth with dental fluorosis. The (93). Therefore, Sealant placed without tooth surface cleaning
choice of sealant material is the key to success. A study found out was having a low retention rate (94). Resin sealant applied on
the total retention of resin sealant (68%) is much higher than glass tooth surfaces brushed with pumice slurry showed a significantly
ionomer sealant (24%) on fluorotic permanent molars of 7- to 10- higher retention rate when compared with no treatment and
year-old children after one year (50). brushing only. Another in vitro study compared the microleakage
of resin dental sealant placed after dry brushing, pumice slurry
cleaning, air polishing and prophylaxis paste polishing (95).
8. Operative factors affecting the Researchers found that air polishing is superior to other
longevity of dental sealant treatment. It was followed by pumice; prophylaxis paste and dry
brushing. However, air polishing is a risk factor for subcutaneous
The longevity of the dental sealant is affected by several emphysema when it is not meticulously handled (96). Therefore,
operative factors when applying dental sealant, including using pumice is suggested.
moisture control of the operative field, tooth surface preparation,
and the application of dental adhesives. These factors should be 8.2.2. Mechanical preparation with dental burs
taken into consideration when applying sealants to enhance the Mechanical preparation with burs is not recommended. A
retention and extend the longevity of the sealants. clinical study found out the difference in the retention rate of
dental sealant between teeth with or without fissurotomy bur
preparation was not statistically significant (97). When
8.1. Moisture control comparing fissurotomy bur, pumice and no preparation, there
was no statistical difference between using fissurotomy bur and
Moisture control should be achieved when placing dental pumice (98). However, the resin sealant placed after both
sealants with no difference for rubber dams, cotton rolls or treatments were having much lower microleakage than no
dental isolation systems. Studies found out the dental sealant preparation. An in vitro study compared microleakage of resin
placed on saliva-contaminated tooth surfaces would significantly sealants placed on tooth surfaces treated with round carbide bur,
increase the microleakage and reduce shear bond strength (85– air polishing, air abrasion, pumice, brushing only and longer
88). These provide us with evidence that moisture control is etching time (99). The microleakage of dental sealant after bur
critical when placing dental sealant. There is no difference in the preparation was superior. However, fissures opened with
retention rate of dental sealant when using rubber dams, cotton mechanical burs might be more susceptible to caries after the
rolls, or dental isolation systems as moisture control. A sealant is lost (100).
randomized clinical trial studied the difference in retention of
resin dental sealant placed with rubber dam isolation or cotton 8.2.3. Mechanical preparation with laser
roll (89). At the 12-month follow-up, no statistical significance Current evidence regarding laser as a surface preparation
was found.Another randomized clinical trial compared cotton method remains inconclusive. Using laser may not be a better
roll and the Isolite system (an illuminated dental isolation system way to increase retention or shear bond strength of dental
with a bite block that provides suction and retraction) as sealant than acid etching. A randomized clinical trial was done

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to compare the effect of conventional acid etching and Er,Cr:YSGG TABLE 2 Clinical protocol for placement of dental sealant.
laser on the retention rate of dental sealant (101). There was no
Step Description [Reference]
statistically significant difference between the two groups after 24
1 Isolation Use cotton rolls, rubber dam or a dental isolation system
months. Another randomized clinical trial comparing Er: YAG, Maintain a clean, dry field for operation (91)
acid etching and Er:YAG before acid etching (102). No 2 Etching Etch the tooth with 37% phosphoric acid for 30 s (113)
statistically significant difference could be found between the Avoid acid gets into contact with the tongue.
groups. Lower shear bond strength was reported when applying 3 Cleaning Clean the tooth surface with pumice slurry (94)
dental sealant with Er:YAG instead of acid etching (103). A Rinse and dry with 3-in-1 syringe and check for frosty
appearance
systematic review and meta-analysis also concluded that using
4 Sealant Place dental sealant with a straight probe or thymosin
Er:YAG before applying dental sealant is not giving a better application instrument
retention rate than conventional phosphoric acid etching (104). Use a straight probe to run through to eliminate any air
While there are studies found out Er:YAG laser combined with bubbles.

acid etching can achieve a higher retention rate and less 5 Light curing Light cure according to the manufacturer’s instructions.
Recommend generally to light cure 20 s.
microleakage (105, 106). However, when considering the
6 Check occlusion Check the occlusion with articulating paper.
technical difficulties, the extra cost and the lengthened
Remove high spot / excess and polish.
procedures, the cost-effectiveness of laser is questionable (107).

8.2.4. Mechanical preparation with air abrasion study found that applying fluoride varnish 24 h before placing
Air abrasion is also not superior to acid etching in increasing resin or resin modified glass ionomer sealant increases the
the retention and penetrability of dental sealant. A clinical study microleakage (116).
compared the retention rate of dental sealants placed with
phosphoric acid etching and air abrasion (108). The time allowed
for the two treatments was the same. The difference in retention
8.3. Application of dental adhesive
was statistically insignificant. Another study came up with the
result that air abrasion prior to acid etching does not increase
Current evidence about dental adhesives application prior to
the retention rate (109). Air abrasion also does not improve the
dental sealant placement is inconclusive. Several studies showed
penetrability of dental sealant from the result of an in vitro
that dental adhesives increase bond strength and reduce the
study (110).
microleakage of resin sealant (88, 117, 118). Among the dental
A systematic review and meta-analysis comparing acid etching,
adhesive systems, the etch-and-rinse dental adhesive system
laser, and air abrasion showed that dental sealant applied with
showed a better effect in increasing the bond strength of resin
phosphoric acid etching would have a lower microleakage than
sealant when compared with the self-etching system (118–120).
Er:YAG laser treatment and air abrasion treatment (111).
On the other hand, a clinical study found the retention rate of
resin sealant with dental adhesives was better than resin sealant
8.2.5. Chemical preparation with acid etching
without dental adhesives at the 3-month follow-up. However,
Acid etching cannot be replaced by any other tooth surface
this difference disappeared at 6-month and 12-month follow-ups
preparation (100). 37% phosphoric acid etching for resin sealant
(121). Some other studies did not find an enhancement in the
is suggested (112). A study compared resin dental sealant placed
retention rate of dental sealant with the addition of dental
with 15 s, 30 s, 45 s and 60 s acid etching time with 37%
adhesives (122, 123). Literature shows strong evidence on the
phosphoric acid gel (113). Dental sealant applied with 60 s
operative factors affecting the longevity of dental sealant. Thus,
etching time gave out a significantly better shear bond strength.
we recommend a step-by-step clinical protocol for sealant
However, when considering the small difference between 30s and
placement in Table 2.
60s, 30s etching time could provide a clinically acceptable result.

8.2.6. Fluoride varnish pre-treatment

Current studies do not support the use of fluoride varnish prior 9. Summary
to dental sealant treatment. Use of fluoride does not increase the
caries preventive effect and retention of dental sealant. The shear Dental sealants can be classified into resin, glass ionomer and
bond strength was adversely affected and the microleakage hybrid sealant with corresponding subgroups. Caries risk, type of
increased. A clinical study compared dental sealant placed 48 h dentition, caries status of a tooth, type of tooth surfaces, eruption
after fluoride varnish application and dental sealant placed status and dental fluorosis are the considering factors. The effect
without prior fluoride varnish and no difference in the retention of dental sealants on preventing and arresting caries is supported
rate was found (114). There was an in vitro study compared by studies published in the recent 10 years. They can effectively
dental sealant placed 5 min after applying fluoride varnish and prevent and arrest caries by providing a physical barrier,
sealant placed without fluoride varnish. The result showed that improving the ease of cleaning, and releasing ions. Among
the mean shear bond strength of dental sealant was hugely different sealants, resin sealant is suggested because of its
reduced with the use of fluoride varnish (115). Another in vitro superior retention and good caries-preventive effect while glass

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Ng et al. 10.3389/froh.2023.1180405

ionomer can be considered when encountering difficult moisture Conflict of interest

control. Various operative factors, including moisture control,
surface preparation and application of dental adhesive, affect The authors declare that the research was conducted in the
the clinical outcomes. absence of any commercial or financial relationships that could
be construed as a potential conflict of interest.

Author contributions
Conceptualization, writing, proofreading: TN, OY.
Proofreading: CC. All authors contributed to the article and Publisher’s note
approved the submitted version.
All claims expressed in this article are solely those of the
authors and do not necessarily represent those of their affiliated
Funding organizations, or those of the publisher, the editors and the
reviewers. Any product that may be evaluated in this article, or
This study was supported by the General Research Fund of claim that may be made by its manufacturer, is not guaranteed
Research Grants Council of Hong Kong SAR, China (No. 17100019). or endorsed by the publisher.

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