DENTINAL SEALANTS: HOW AND WHEN TO USE SEALANTS TO TREAT UNCOMPLICATED CROWN FRACTURES Glenn Brigden, DVM, DAVDC Jennifer Tjepkema, DVM 511 Saxony Place, Ste 100, Encinitas, CA 92024 (760) 230-1818 t • (760) 452-7770 f • www.PCVetDentistry.com • [email protected] Page 2 of 3 DENTINAL SEALANTS: HOW AND WHEN TO USE SEALANTS TO TREAT UNCOMPLICATED CROWN FRACTURES In order to understand how and when to use dentin- ment of the odontoblastic processes and stimula- al sealants to treat uncomplicated crown fractures, tion of the A-Delta fibers within the pulp, resulting an understanding of the important relationship den- in PAIN. tin has with the pulp and enamel must be achieved. Dentinal tubules are greater in number and larger Dentin is a porous, hard organic (30%) and inorganic in diameter the closer they are located to the pulp. (70%) substance that is covered by enamel (crown) Clinically, this means that the deeper the fracture, and cementum (root). Unlike enamel, dentin is the more dentinal tubules are exposed to the oral continually made through out the life of the tooth. cavity/bacteria. The more dentinal tubules exposed, Although it appears grossly as a solid structure, mi- there is a greater potential for pain and increased croscopically dentin is made of three structures: risk for pulp necrosis. Dentinal tubules provide a dentinal tubules that extend to the pulp, intertubu- conduit for oral bacteria to have direct access to the lar dentin that makes the bulk of dentin and peri- pulp, which could cause irreversible pulpitis and tubular dentin that has a higher crystalline content pulp necrosis. than the intertubular dentin. The dentinal tubules contain odontoblastic processes from odontoblasts Uncomplicated crown fractures need to be treated located within the pulp. Nerve fibers, specifically A- because they could cause pain and/or infection re- Delta fibers, are wrapped around odontoblasts. sulting in tooth death. The treatment protocol will depend on which tooth is fractured, how the tooth is Odontoblasts are cells that form new dentin. There fractured, the depth, and the location. are three types of dentin: primary dentin, which is the dentin that is present when the tooth For example, superficial slab fractures on erupts, secondary dentin, which is the new the buccal aspect of the fourth premolar dentin laid down as the tooth ages and tertia- are good candidates for sealant alone (as ry dentin, which is reparative dentin. Tertiary long as the tooth is vital) but deeper frac- dentin is less organized than secondary or pri- tures at this location might require a true mary dentin and appears brown and shiny. This “restoration” with composite. The most com- dentin is laid down when there is injury to the tooth mon fractures that are treated with a sealant are: such as from chronic wear (ball chewing) or after an uncomplicated fractures involving the cusps of the uncomplicated crown fracture. premolars or mandibular first molars, teeth treat- ed with odontoplasty and in cases of hypoplastic Dentin is composed of tubules that connect the enamel treatments (enamel hypocalcification/hy- pulp to the enamel. The dentinal tubules contain poplasia). fluid, nerves and odontoblastic processes. This means that dentin and the pulp have an integrated Examples of when to not use sealants are: non- relationship; therefore, damage to the dentin affects vital teeth, teeth with resorptive lesions affecting the pulp and damage to the pulp affects the dentin. the crown, teeth with complicated crown fractures This is why the pulp canal is wider in non-vital teeth or caries lesions. Sealants are also not permanent compared to the other dentition and the reason why and might need to be replaced in the future. The fre- uncomplicated crown fractures can result in pulp quency of re-application depends on the chewing necrosis. habits of the patient and if reparative dentin is pres- ent (typically do not seal if tertiary dentin is present). There are three afferent nerves that are responsible Treated teeth need to be radiographically moni- for odontogenic (tooth) pain: A-Beta, A-Delta and C- tored to ensure that the tooth has not died. This can fibers. A-Delta fibers are stimulated when dentin is results due to an inadequate seal, pulpitis present exposed to changes such as temperature, osmolal- prior to procedure or secondary to the initial insult ity (sweet or salty foods) or external stimuli touching (contusion resulting in tooth death). dentin (eating/ chewing toys). This results in fluid movement within the dentinal tubules and move- 511 Saxony Place, Ste 100, Encinitas, CA 92024 (760) 230-1818 t • (760) 452-7770 f • www.PCVetDentistry.com • [email protected] Page 3 of 3 DENTINAL SEALANTS: HOW AND WHEN TO USE SEALANTS TO TREAT UNCOMPLICATED CROWN FRACTURES Odontoplasty is defined as an adjustment of the to remove the solvent and thin the layer of the seal- tooth contour. This procedure needs to be per- ant. This can be performed with a 3-way air-water formed prior to sealing fractures but sometimes this syringe. To prevent oil from being blown onto the procedure is performed as a primary treatment. For tooth from the syringe, it is recommended to “push” example after extraction of the maxillary fourth pre- the air button on the syringe away from the tooth, molar in dogs and cats the cusps of the mandibular and then without letting go of the button, to move first molar are “flattened” and ”rounded” in a man- the syringe over to the tooth. The oil from the syringe ner that would prevent the cusps from traumatizing will be expelled prior to drying the tooth. After evap- the opposing hard palate when the tooth contacts oration of the solvent, the area should be light cured the tissue. The tooth contacting the hard palate for 15-30 seconds (please refer to manufacturer’s is a result of the extraction of the opposing fourth recommendations). premolar. The “contouring” of this tooth is referred to as an odontoplasty. Whenever this procedure is There are 7 dentinal sealant/adhesive generations performed enamel is removed potentially exposing present on the market. The most commonly used dentin thus requiring to be sealed. for this procedure are 5th generation. These den- tinal sealants contain the primer and adhesive in To prepare a fracture site or hypoplastic enamel for one bottle. Our favorite at Pacific Coast Veterinary dentinal sealant the recipient site should have all of Dentistry is 3M ESPE Adaper Single Bond; it is a more the unsupported enamel/dentin removed and then expensive product but has proven in our hands to contoured (odontoplasty) to prevent future frac- work superior to other generic/cheaper brands. tures, plaque retention and allow better reten- tion of the sealant. Typically diamond burs, It is very important to treat uncomplicated fine or medium course tapered diamond burs crown fractures because if left untreated, are recommended. A favorite is a “football” it could lead to the death of that affected shaped diamond bur, which allows excellent tooth and/or dental pain. It is also essen- contouring. After the odontoplasty the tooth tial to recognize which teeth are and are not should be cleaned, smear layer removed and good candidates for this treatment. dentinal tubules “opened”, which can be achieved with acid etchants. References: The most common acid etchant used in dentistry is phosphoric acid at a 37-38% concentration. This 1) Hargreaves K, Cohen S., Cohen’s Pathways of the acid is typically not irritating to soft tissue, but protec- Pulp 10th ed. St. Louis 2011 tion of the gingiva is recommended (gauze wrapped around the tooth works well). The etchant should 2) Wiggs B, Lobprise H. Oral anatomy and physiolo- gy. In: Veterinary Dentistry Principles & Practice. Phila- sit on the tooth between 15-30 seconds (please ad- delphia 1997:62:64 here to manufacturer’s recommendation) and then rinsed (wiping the etchant off the tooth with water 3) Kimberlin L, Brown. Comparison of Shear Bond- soaked gauze works very well). The area should look ing Strength for Two Different Etching Systems in Ca- “chalky”. If it does not, then this step should be re- nine and Human Dentin. J Vet Dent 28 (4); 242-249, peated. Etchant should only be applied to the re- 2011. cipient site, and unaffected enamel should not be etched because it will cause it to demineralize. 4) Robb L, Marx J, Steenkamp G, Heerden WF, Preto- rius E, Boy SC. Scanning Electon Microscopic Study After the etchant has been removed, the tooth of the Dentinal Tubules in Dog Canine Teeth. J Vet should be blotted dry with a cotton pellet or gauze. Dent 24 (2); 86-89, 2007. Once the tooth is dried, 2-3 consecutive coats of 5) Hernandex SZ, Negro VB, Paulero RH, Toriggia PG, the sealant should be applied for 15 seconds with Saccomanno DM. Sacnning Electron Microscopy of gentle agitation while using a fully saturated brush Pulp Cavity Dentin in Dogs. J Vet Dent 27 (1)7-11, to the prepared site. Gently air dry for 15 seconds 2010 511 Saxony Place, Ste 100, Encinitas, CA 92024 (760) 230-1818 t • (760) 452-7770 f • www.PCVetDentistry.com • [email protected].