Introduction
Dental caries is a highly prevalent oral condition that shows deleterious outcomes for each patient and the public regarding medical, social, and economic concerns (Cvikl et al.
2018). A significant number of dental caries affecting children and younger age groups is limited to the occlusal aspects of the erupting permanent molars (Carvalho
2014; Ahovuo-Saloranta et al.
2016). Pit and fissure caries constitute 44% of all caries involving the primary teeth and 80–90% in the permanent teeth (Beauchamp et al.
2008). This is because the pits and fissures are inaccessible for cleaning with the help of toothbrushes, thereby retaining plaque (Szoke
2008; Carvalho et al.
2016). The application of dental sealant forms a barrier physically on the tooth surface and lessens the growth of microbes by blocking their nutrition (Ahovuo-Saloranta et al.
2016). Sealants are not only efficient in preventing dental caries, but also reliable evidence shows that they have the potency to stop the advancement of white spot lesions (Wright et al.
2016).
The routinely used pit and fissure sealants include resin sealants and glass ionomer sealants. The disadvantages of using resin-based materials as sealants include polymerization shrinkage and moisture sensitivity. While polymerization shrinkage potentially results in microleakage, moisture sensitivity limits its usage in difficult-to-isolate cases (Kantovitz et al.
2008; Mehrabkhani et al.
2015; Bhat et al.
2013). Moreover, a stronger biofilm might be seen accumulating on resin-based materials (Yu et al.
2016). On the other hand, when used as a sealant, glass ionomer cement often fractures due to its limited strength to withstand masticatory loads (Feigal and Donly
2006). Compromised retention is another drawback (Bhat et al.
2013).
Bioactive materials are a fairly recent addition to dentistry. They are reported to release more fluoride compared to glass ionomers. Their unique chemistry not only boosts the natural remineralization process but also aids in forming a seal between the tooth and the material. Additionally, they respond to the changes in the salivary pH by taking up calcium, phosphate, and fluoride ions hence balancing the tooth’s chemical composition (Kaushik and Yadav
2017). One such recently introduced smart material is ACTIVA BioACTIVE-Base/Liner (Pulpdent, USA). According to its manufacturers, it is the perfect blend of the strength and aesthetics of composite resins as well as the beneficial properties of glass ionomer cements such as release, and recharge of calcium, phosphate, and fluoride ions, moisture tolerance, and chemical bonding (Amaireh et al.
2019).
The aforementioned properties of ACTIVA BioACTIVE-Base/Liner instigated us to evaluate its ability to be used as a pit and fissure sealant. The sealant’s penetration depth that affects the retention is another factor that determines the longevity of pit and fissure sealants (Grewal and Chopra
2008; Symons et al.
1996). Thus, this study was conducted to comparatively evaluate the sealing ability and penetration of a bioactive material used as pit and fissure sealant. The null hypothesis for the study was set as there will not be any difference in the sealing ability and penetration of a bioactive material used as a pit and fissure sealant when compared to those of GIC sealant.
Results
Out of the 20 teeth used in the present study, 3 were permanent molars (2 mandibular and 1 maxillary) and the remaining 17 teeth were premolars (14 maxillary, 3 mandibular). Following the random distribution of the samples, Group I had one mandibular molar, seven maxillary premolars, and two mandibular second premolars, while Group II consisted of one mandibular molar, one maxillary molar, seven maxillary premolars, and one mandibular second premolar. The frequency distribution of various types of fissures seen among the selected teeth is shown in Table
1. Fissure types I, IK, U, and V were found to be statistically non-significantly distributed between the two groups. In the comparison of the sealant penetration, the two groups did not show a significant difference, statistically (
p = 0.104, Table
2). Similarly, the microleakage scores between the two groups also did not show any significant difference (
p = 1.0, Table
3).
Table 1
Frequency distribution of various types of fissures across two groups
Fissure morphology |
I |
Count | 4 | 1 | 5 |
% Within group | 40.0% | 10.0% | 25.0% |
IK |
Count | 1 | 0 | 1 |
% within Group | 10.0% | 0.0% | 5.0% |
U |
Count | 1 | 6 | 7 |
% Within Group | 10.0% | 60.0% | 35.0% |
V |
Count | 4 | 3 | 7 |
% Within group | 40.0% | 30.0% | 35.0% |
Total |
Count | 10 | 10 | 20 |
% Within group | 100.0% | 100.0% | 100.0% |
Pearson Chi-square | 6.514 | 3 | 0.089 |
Table 2
Independent t test to compare the sealant penetration property between the two groups
Sealant penetration depth | 0.93 ± 0.42 | 0.9 ± 0.72 | 0.099 | 0.922 |
Length of unfilled space | 0.32 ± 0.6 | 0.02 ± 0.06 | 1.593 | 0.145 |
The total length of the fissure | 1.38 ± 0.74 | 1.62 ± 1.24 | − 0.536 | 0.6 |
Penetrability | 0.73 ± 0.24 | 0.52 ± 0.3 | 1.712 | 0.104 |
Table 3
Comparison of the microleakage scores between the two groups
Microleakage scores |
Score 0 |
Count | 6 | 6 | 12 |
% Within group | 60.0% | 60.0% | 60.0% |
Score 2 |
Count | 2 | 2 | 4 |
% Within group | 20.0% | 20.0% | 20.0% |
Score 3 |
Count | 2 | 2 | 4 |
% Within group | 20.0% | 20.0% | 20.0% |
Total |
Count | 10 | 10 | 20 |
% Within group | 100.0% | 100.0% | 100.0% |
Pearson Chi-square | 0.000 | 2 | 1.000 |
Discussion
Currently, resin-based pit and fissure sealants are being popularly used worldwide. But, the resin sealants predispose to the accumulation of biofilms due to microleakage (Lin
2017; Spinell et al.
2009; Sun et al.
2009). Thus, fluoride-releasing pit and fissure sealants are more beneficial due to their anti-cariogenicity and remineralizing efficiency (Xu et al.
2006; Xu and Burgess
2003). In addition, the fluoride release from sealants can also help to enhance the hardness of underlying demineralized enamel and dentin (Sivapriya et al.
2017). Absolute isolation is also a critical factor for the retention and success of resin-based sealant materials (Sreedevi et al.
2022). But, pediatric dentistry does not vow total isolation, especially in cases where patient compliance is limited. Thus, moisture-friendly sealants and sealants requiring less number of steps during placement are more appropriate (Garg et al.
2019). Caries progression, under the sealed surface, is another concern that demands the usage of a sealant having a quintessential ability to remineralize (Netalkar et al.
2022). Keeping in mind the aforementioned factors, in the present study, we explored the possibility of using ACTIVA BioACTIVE-Base/Liner, which is bioactive, fluoride-releasing, moisture friendly, and has also got remineralizing potential as a pit and fissure sealant.
ACTIVA BioACTIVE Base/Liner is indicated to be used as an alternative to all types of glass ionomer cements, and flowable composites and can be used without etchants or bonding agents, thereby offering a quick chairside procedure (Vouzara et al.
2020). It is a “light-cured resin-modified calcium silicate”, manufactured as an uncompromised blend of the uniqueness of composites (strength, esthetics, and physical properties) and glass ionomer cement (fluoride release) (Kunert and Lukomska-Szymanska
2020). Chemically, the material consists of Bioactive glass as a filler in a diurethane and methacrylate base with a modified polyacrylic acid and polybutadiene-modified diurethane dimethacrylate (rubberized resin) (van Dijken et al.
2019). During critical pH, this material is capable of releasing and recharging ions such as calcium, phosphate, and fluoride in greater quantum than the glass ionomers. Thus, it can efficiently stimulate apatite crystal formation, thereby helping remineralization. Additionally, the strong and resilient resin matrix of this bioactive cement does not chip or crumble. ACTIVA BioACTIVE Base/Liner is biocompatible and is free of Bisphenol A, Bis-GMA, and BPA derivatives (Karabulut et al.
2020).
One of the ideal requisites of a material to be used as pit and fissure sealant is obtaining a good seal (Garg et al.
2019). Therefore, we studied microleakage as one of the properties when ACTIVA BioACTIVE Base/Liner is used as a sealant. We used the methylene blue dye penetration test, which is not only an inexpensive and easily accomplished test but is also known to be a reliable method of testing microleakage at the sealant margins (Agrawal and Shigli
2012; Kramer et al.
2008). While the method is associated with the concerns of acute methylene blue toxicity upon oral intake (Amend et al.
2021), it should be noted that the present study was carried out in vitro.
We found no difference in the microleakage of the tested material in comparison to glass ionomer sealant. Jain et al. (
2022) also have found no difference in the microleakage scores between ACTIVA BioACTIVE and glass ionomer cement. Similarly, Kaushik and Yadav (
2017) also reported no statistical difference in the microleakage of ACTIVA BioACTIVE compared to that of nanohybrid composite. On the contrary, a study by Tohidkhah et al. (
2022) showed that ACTIVA BioACTIVE exhibited higher microleakage than incrementally filled composites and resin-modified glass ionomer cement. A common observation was made in the studies by Kaushik and Yadav (
2017) and Tohidkhah et al. (
2022) that etching and applying a bonding agent while restoring the tooth using Activa Bioactive significantly reduces microleakage. Interestingly, the study by Jain et al. (
2022) also etched the tooth and applied a bonding agent while placing the restoration. However, all these studies have used ACTIVA BioACTIVE restorative, while the present study has used ACTIVA BioACTIVE Base/Liner. In the present study, etching was not done before sealing the tooth using ACTIVA BioACTIVE Base/Liner. We followed the manufacturer’s instructions for placement.
For a material to be used as pit and fissure sealant, most importantly, it should possess good flowability to enable its penetration into the deep pits and fissures completely thereby establishing a good mechanical barrier (Cvikl et al.
2018). Thus, another parameter we chose to evaluate in the present study is penetration. ACTIVA BioACTIVE Base/Liner has got a film thickness of about 11 µm when mixed as per the manufacturer’s recommendations. Our study showed statistically no difference in the penetration depth of ACTIVA BioACTIVE Base/Liner in comparison to glass ionomer sealant. The fissure pattern is known to influence the penetration depth of the sealant. Muntean et al. (
2019) reported the greatest penetration of the sealant in U-type fissures and the least in I-type fissures. Thus, we evaluated the fissure pattern distribution in each group and it was found that there was no difference in the distribution of different fissure patterns between the groups.
Activa bioactive smart material is a recent addition to the dental materials available in the market and to the best of our knowledge, research exploring ACTIVA BioACTIVE Base/Liner is limited. The findings of the present study accept the set null hypothesis, however, within the following limitations. This is a pilot study conducted in vitro evaluating only two important properties of a pit and fissure sealant. There are many other critical factors that a sealant should possess apart from penetration and microleakage, which were not evaluated in our study. Also, this study compared the tested properties of the ACTIVA BioACTIVE Base/Liner smart material to glass ionomer sealant and not the resin-based sealant. In addition, in the present study, we did not standardize the sample to any one type of tooth. We used both molars and premolars. Thus, future studies have to be conducted exploring ACTIVA BioACTIVE Base/Liner as a pit and fissure sealant.
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