口腔预防医学：窝沟封闭

1、窝沟封闭（Pit-and-fissure sealants）窝沟封闭于1967年由Cueto and Buonocore首次报道，今天在牙科被广泛应用和推荐。儿童的点隙窝沟龋流行病学流行率: 咬合面龋损占总的龋损的50.9% 67 years old 44% 1214 years old 65%氟化物防龋对窝沟龋效果不理想 窝沟是龋损易发部位咬合面的解剖结构 容易滞留细菌有机塞、 食物残渣、 菌斑阻塞窝沟点隙，阻止了氟化物的渗透较薄的牙釉质层 对龋病易感 窝沟的解剖形态窝沟的分类V型 浅而宽，容易清洁I 型 深而窄，容易滞留食物残渣和细菌，不易清洁 窝沟龋的发展龋损首先发生在侧壁进展至窝沟底部

2、三角形病损进展期 预防窝沟龋的历史回顾预防性充填法（Prophylactic odontotomy）制备I类洞，银汞充填窝沟磨除术（Prophylactic odontoplasty）以圆钻磨除深窝沟窝沟封闭（Pit and fissure sealant） 窝沟封闭的发展历史第一代: 365nm 紫外光固化, 操作时间长, 效果不理想第二代: Bis-GMA, 化学固化第三代: 430490nm 可见光, 方便，效果好 3M Consise sealant第四代: 释氟性窝沟封闭剂 Pulpdent sealant窝沟封闭适应证萌出少于4年磨牙深的、易滞留、窄的窝沟点隙窝沟有软化和混浊倾向其

3、他牙齿有咬合面或光滑面龋；被封闭牙没有邻面龋患者接受适当的全身性或局部用氟，但仍然龋活跃窝沟封闭非适应证牙齿萌出四年以上，窝沟经常有色素沉着牙齿未完全萌出，有牙龈覆盖除非患者为龋活跃个体，否则前磨牙不作窝沟封闭牙面窝沟浅而宽，自洁作用好患牙有邻面龋，已有咬合面龋洞（需用充填治疗）患者饮用水源不含氟，患者不能配合龋病预防计划封闭剂成分树脂基质Resin baseBis-GMA稀释剂Thinner (dicrease the viscosity) methyl methacrylate (MMA) et al.引发剂Initiator self-cure light-cure (430490nm

4、visible light)填料Filling (increase the compressive strenth, rigidity and abrasive resistance)颜色Color (easy to identify)酸蚀技术1955由Buonocore首先介绍3538% 磷酸恒牙30秒 乳牙60 秒 有机质含量高 更耐酸酸蚀使光滑的牙釉质表面变得不规则，增加其表面自由能。当液体树脂基质置于不规则的酸蚀表面，树脂通过毛细管作用浸入表面，单体聚合，树脂扣入牙釉质表面。树脂微突的形成是封闭剂-牙釉质粘结的基本机制。酸蚀技术牙釉质酸蚀形成三种微结构形式:釉小柱核心溶解，周围不溶解釉

5、小柱周围溶解，核心完好不典型形态操作步骤牙面清洁Teeth cleaning酸蚀Acid-etch冲洗吹干Washing and evaporation放置封闭剂Sealant application封闭剂固化Solidify of sealants检查Examination操作步骤牙面清洁Teeth cleaning cleaning teeth thoroughlyslow speed hand piece, mini dental brush or rubber cap, pumice powder or dentifrices without fluoride注意: 不能使用脂类清洁剂

6、或含填料的磨料必要时去除可疑龋操作步骤酸蚀Acid-etch35% 磷酸, 2/3 牙尖斜面, 恒牙 30s, 乳牙60s,注意:轻轻搅拌以保证牙面接触新鲜的酸，不能污染酸蚀面，酸蚀后的白垩色操作步骤冲洗和干燥Washing and evaporation彻底冲洗以去除酸及反应产物, 以压缩空气或无色酒精干燥注意：不污染酸蚀面,白垩色操作步骤放置封闭剂自凝性Self-cure sealants: mixing for 10s to 15s, apply in 45s.光固化Light-cure sealants: apply on acid-etched surfaces, fully pen

7、etration of sealant into the fissures, enough thickness to provide enough compressive strenth, rigidity 操作步骤封闭剂的固化Solidify of sealants自凝性self-cure sealants: 12 minutes 光固化light-cure sealants: 430490nm visible light, 1mm distance, 2040s操作步骤6. 检测及调牙合（必要时）固化情况、粘结、气泡、遗漏点隙、过度封闭、调牙合检查 after 3 months, 6 mo

8、nths or 1 year interval,脱落重新封闭临床效果临床评价保留率retention rate = 封闭剂保留的牙数/所有检查的牙齿X100%龋降低相对有效率 relative effectiveness of decreased dental caries =（对照组患龋率-实验组患龋率）/对照组患龋率X100%临床效果Sealants, by providing a physical barrier, inhibit microorganisms and food particles from collecting in pits and fissures. Sealant

9、s are highly effective in preventing dental caries in pits and fissures of teeth when applied by trained operators. Sealant should be placed on pits and fissures of childrens and adolescents permanent teeth when it is determined that the tooth or the patient is at risk of developing caries. Fissure

10、sealing can be recommended as a caries preventive measure.Judit S. Fissure sealing. A review, Fogorv Sz. 2008 Aug;101(4):137-46.与临床效果有关的其他因素下颌保留率比上颌高前磨牙保留率比磨牙高大多数脱落发生在前6个月，重新封闭增加了龋病预防效果成功率因牙齿的选择、术者的技巧、工作态度而异Systematic evaluation of clinical effectivenessClinical effectiveness of resin sealants to pe

11、rmanent teethThe relative caries risk reduction pooled estimate of resin-based sealants on permanent 1st molars was 33% (relative risk = 0.67; CI = 0.55-0.83). The effect depended on retention of the sealant. In conclusion, the review suggests limited evidence that fissure sealing of 1st permanent m

12、olars with resin-based materials has a caries-preventive effect. The evidence is incomplete for permanent 2nd molars, premolars and primary molars and for glass ionomer cements.Mejare I, et al. Caries-preventive effect of fissure sealants: a systematic review. Acta Odontol Scand. 2003 Dec;61(6):321-

13、30. Systematic evaluation of clinical effectivenessClinical effectiveness of resin sealants to permanent teethResin sealants are effective in preventing dental caries on occlusal surfaces of permanent teeth. The evidence is incomplete for primary teeth. Clinical effectiveness of glass ionomer (GIC)

14、sealants Evid Based Dent.2010;11(1):10. doi: 10.1038/sj.ebd.6400700.Glass ionomerand resin-based fissure sealants - equally effective? RESULTS:Out of 25 selected studies, 11 met the inclusion criteria (eight were trials and three were systematic reviews) with six of these being included in a meta-an

15、alysis. The pooled odds ratio was 0.96 (95% confidence interval, 0.62-1.49), indicating no difference in the caries-preventive effect ofglass ionomercements (GIC) and resin-based fissuresealantmaterial.Clinical effectiveness of glass ionomer (GIC) sealantsCONCLUSIONS:GIC and resin-based sealants exh

16、ibited significant caries-preventive effects. Thisreviewfound no evidence that either material was superior to the other in the prevention of caries. Therefore both materials appear to be equally suitable as fissuresealantmaterials.Longevity of materialsDent Mater.2012 Mar;28(3):298-303. Longevity o

17、f materials for pit and fissure sealing-results from a meta-analysis.Longevity of materials98 clinical reports and 12 field trial reports were identified. Auto-polymerizing sealants had the longest observation time (up to 20 years) and were found to have a 5-year retention rate of 64.7% (95%CI=57.1-

18、73.1%), which was estimated from the meta-analysis model. Resin-based light-polymerizing sealants and fluoride-releasing products showed similar 5-year retention rates (83.8%, 95%CI=54.9-94.7% and 69.9%, 95%CI=51.5-86.5%, respectively) for completely retained sealants. Poor retention rates were docu

19、mented for UV-light-polymerizing materials, compomers andglass-ionomer-cement-based sealants (5-year retention rates were 19.3%). Retention rates for UV-light-polymerizing materials, compomers andglass-ionomer-cement-based sealants were classified as inferior.CONCLUSIONS VERSUS SIGNIFICANCE:The resu

20、lts of this meta-analysis suggested that resin-based sealants can be recommended for clinical use. The faster and less error-prone clinical application of light-polymerizing materials, however, makes them the preferred choice for daily dental practice.Longevity of materialsPLoS One.2013 Oct 23;8(10)

21、:e77103. Validity ofsealantretention as surrogate for caries prevention-a systematicreview.RESULTS:The risk of loss of complete retention ofsealantmaterials was associated with the risk of caries occurrence for resin but not for GIC basedsealants. The difference between RCR values of the twosealantt

22、ypes was statistically significant (p0.05). The null-hypothesis was rejected.CONCLUSIONS:The current clinical evidence suggests that complete retention ofpit and fissure sealantsmay not be a valid surrogate endpoint for caries prevention as its clinical endpoint. Further research is required to corr

23、oborate the current results.Longevity of materialsSystematic evaluation of clinical effectivenessCochrane Database Syst Rev.2013 Mar 28;3:CD001830. Sealants for preventing dental decay in the permanent teeth.CONCLUSIONS:The application of sealants is a recommended procedure to prevent or control car

24、ies. Sealing the occlusal surfaces of permanent molars in children and adolescents reduces caries up to 48 months when compared to nosealant, after longer follow-up the quantity and quality of the evidence is reduced. Thereviewrevealed that sealants are effective in high risk children but informatio

25、n on the magnitude of the benefit of sealing in other conditions is scarce. The relative effectiveness of different types of sealants has yet to be established.New developments of sealantsEur J Paediatr Dent.2016 Mar;17(1):17-23.Evaluation of shear bond strength, penetration ability, microleakage an

26、d remineralisation capacity of glass ionomer-basedfissuresealants.RESULTS:The Fuji Triage exhibited the lowest microleakage and unfilled area proportion (p0.05). The highest shear bond strength was calculated with Fuji VII EP (p0.05). The fluoride content for all treatment groups was significantly d

27、ifferent when remineralisation values were compared to demineralisation (p0.05).CONCLUSION:Both the Fuji Triage and Fuji VII EP yielded compatible and satisfactory results and allfissuresealantsused in this study are sufficient as anti-caries agents.Other issues related to pit and fissure sealantsTh

28、e susceptibility to dental caries after acid etchthe solubility of acid-etched teeth in acidic solution was similar to that of non acid-etched teeththe dental caries decreased even if the sealants disengaged.Contamination of saliva after acid-etchcontamination of saliva prevent the formation of resi

29、n microtag disengagement of sealants or invading of bacterials dental cariescompressed airrubber and cotton rollsre-application of acid after exposure to saliva for 160s影响窝沟封闭预防效果的因素窝沟封闭对预防龋病是有效的自凝性封闭剂比光固化的更有效封闭剂的预防效果随时间递减封闭剂和加氟联合预防效果更好Liodra JC, et al. Factors influencing the effectiveness of seala

30、nts-a meta-analysis, Community Dent Oral Epidermal 1993,21:261-8窝沟封闭的其他问题酸蚀后牙面的龋易感性即使封闭剂脱落，酸蚀后牙面在酸性溶液中的溶解度与未酸蚀牙面相近酸蚀后牙面唾液污染唾液污染阻止了树脂微突的形成，造成封闭剂脱落、细菌侵入，引起龋齿以压缩空气、橡皮障或棉卷隔湿唾液污染后重新酸蚀窝沟封闭的其他问题早期窝沟龋的封闭1. 酸蚀 杀死窝沟中的微生物2. 封闭剂 阻止细菌的营养供应3. 酸蚀后少于3% 细菌存活在窝沟封闭后早期龋停止进展封闭性充填Sealant restorationThe sealant restoration is indicated primarily on the occlusal surfaces of permanent molars and premolars and may also be indicated for primary molars. They are most appropriate when