How my fissure sealants went wrong (and how to make sure it doesn’t happen to you)

This week upon treating a 15 year old anxious girl, it became part of our plan to deliver fissure sealants. As per standard protocol, I picked up my rubber cup and paste and began to clean the occlusal surface. The child is already squirming as if we had just drilled straight into her pulp!

(Fun fact: in cases of extreme anxiety and phobia, there is evidence to show that some people have real pain signals fired in their brain as shown by an electroencephalogram or EEG. An EEG is a test that detects the electrical activity of your brain. So even though you know there’s no way the rubber cup can be painful, be sympathetic to the fact that their brain may be sending actual false pain signals due to their anxiety. For example, if you placed your hand on a table under a blanket, and then a fake hand that looked like yours was on the table next to it - and then I hit the fake hand with a hammer, you may feel a sensation of pain as your brain perceives the stimulus to be painful.)

Anywayyy, next stage. Boom. Isolation with cotton wools and dry guards. Etch, wash, dry.

Fissure sealant applied ever so gracefully and diligently to the buccal pit and 1/3 cuspal incline of the occlusal surface. I was thinking to myself this must be perfect. Light cure, done.

“WELL DONE ____, YOU DID SO WELL! I’LL GET YOU A STICKER”

…

The tutor comes over and quickly checks the fissure sealant. They effortlessly flick out the weakly bonded fissure sealants and tell me that I’ll have to redo them.

What went wrong?

The Takeaway Lessons:

• There was a subtle glazing of calculus on the occlusal surface of the tooth. For one, despite being told to do the fissure sealant, I should have independently checked if their treatment plan had been made and what had been done as part of the stabilisation phase. Placing fissure sealants in unhealthy mouths isn’t a good idea AND it prevents the adhesion of resin. Supra-gingival scaling was booked for the next appointment. Plus let’s think about how this sealant is actually being retained. It relies on micro-mechanical retention from the selectively demineralised enamel. How can this occur if the fissures are covered by calculus?

• I did all the protocol for moisture control, but I realised in retrospect that the tooth probably wasn’t completely dry. Saliva has a way of slowly seeping onto the occlusal surface even if not in direct contact with the tongue or mucosa. Moisture even contaminates an etched surface so it really needs to be completely dry the entire time. A good tip for moisture control is to keep your hand in the patient’s mouth the entire time and let your nurse help you grab materials. Just like during an extraction where you support the alveolus, keep your thumb on side of the tooth and your first finger on the other side and don’t move them! This will stop the child biting down. Worst case scenario, use a bonding agent but don’t just apply the fissure sealant if you can see the tooth is no longer dry, you’re just wasting your time and you will have to redo it.

• Instead of telling a child “we’re almost finished”, use different methods such as just starting a countdown down from 10. This avoids making false promises if you end up needing to repeat treatment, and you could lose the child’s trust. Choose your language and vocabulary very carefully