journal of dentistry 41 (2013) 590–599

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Effect of pit and fissure sealants on caries detection by a

fluorescent camera system

Kenneth Markowitz a,*, Dalia Rosenfeld b, Daniel Peikes b, Gerald Guzy b, Glenn Rosivack b
a
Department of Oral Biology, New Jersey Dental School, University of Medicine and Dentistry of New Jersey, 185 South Orange Avenue,
Newark, NJ 07103, USA
b
Department of Pediatric Dentistry, New Jersey Dental School, University of Medicine and Dentistry of New Jersey, 185 South Orange Avenue,
Newark, NJ 07103, USA

article info abstract

Article history: Objective: The aim of this study was to evaluate the effect of sealant placement on the
Received 18 February 2013 detection of caries by a fluorescent camera (FC), the Spectra caries detector.
Received in revised form Materials and methods: In a laboratory study, FC images and readings were obtained from 31
6 May 2013 extracted teeth, before and following application of clear sealants (Shofu Clear or Delton
Accepted 7 May 2013 unfilled), or opaque sealants (3M Clinpro or Delton FS). Teeth were then sectioned and
examined for enamel or dentine caries. Using each tooth’s true caries diagnosis, the
sensitivity and specificity of the FC measurements in detecting dentine caries was calcu-
Keywords: lated. In the clinical study, FC readings were obtained from 41 molars in children prior to and
Caries following application of clear sealants.
Diagnosis Results: Following application of Shofu or Delton unfilled there were reductions in the mean
Fluorescence FC readings of 10% ( p = 0.5) and 8.2% ( p = 0.009), respectively. Application of two opaque
Sealants sealants, 3M or Delton FS significantly reduced mean FC readings 16.2% and 20.8% ( p < 0.5),
Sensitivity respectively. Although the carious lesions could still be observed in FC images from teeth
Specificity with opaque sealants there was a significant loss of sensitivity in detecting dentinal caries.
Clear sealant application caused an insignificant loss of detection sensitivity. Following
application of clear sealants to children’s molars there was a small (4.01%) but significant
( p < 0.01) reduction in FC readings recorded from these teeth.
Conclusions: The FC can detect caries under clear sealants with little loss of sensitivity.
Although lesions can be seen through opaque sealants, loss of sensitivity precludes accurate
lesion assessment.
# 2013 Elsevier Ltd. All rights reserved.

5–20 nm. In addition to the clear sealants there are also a

1. Introduction
Pit and fissure sealants are a widely used means of preventing
the development of occlusal caries.1 There are many different
types of sealants; most of them are composed of bisphenol-A-
glycidyl-methacrylate (bis-GMA) resins. They can be classified
as clear (unfilled), opaque (filled with silica particles), and
nanofilled with zirconia or silica particles with size range of
variety of colours available, including tooth colour, pink,
green, grey and yellow. Ideally, pit and fissures sealants should
not be placed over obvious caries, but may be placed over
clinically inapparent carious lesions. Decay does not appear to
progress under sealed occlusal surfaces.2–4 Following 5-years,
sealed fissures were found to harbour few viable bacteria in
comparison to contralateral un-sealed molars in the same
subjects.5

* Corresponding author. Tel.: +1 973 972 0253; fax: +1 973 972 0045.
E-mail address: markowkj@umdnj.edu (K. Markowitz).
0300-5712/$ – see front matter # 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jdent.2013.05.005
 journal of dentistry 41 (2013) 590–599
The use of sealants on decayed surfaces is not without risk
since the bonding of the sealant material to caries affected
tooth structure is poor.6 In clinical practice, the decision to seal
a tooth is frequently based on imperfect information since
clinical and radiographic examinations are not accurate
methods of assessing the extent and depth of occlusal caries.7
Since sealed teeth do occasionally decay,8,9 dental practi-
tioners should monitor all sealed teeth to make sure that the
sealant and the tooth surfaces remain intact, and that the
caries process does not show signs of initiation or progression.
Monitoring sealed teeth for evidence of caries initiation and
progression may be challenging, particularly in teeth treated
with opaque sealants that preclude direct visualisation of the
occlusal anatomy.
Several studies have attempted to evaluate the effect of pit
and fissure sealants on the ability of dentists to detect occlusal
caries. These studies have examined the impact of sealants on
the accuracy of visual caries detection and on the performance
of various devices used to detect caries. Clear sealants impede
visual caries detection, resulting in fewer lesions being
detected and fewer teeth being treatment planned for
restorative intervention.10 In this study the poor sensitivity
of visual examination in detecting enamel and dentine caries
was further deteriorated by sealant application.
The effect of clear and opaque sealants on laser fluores-
cence (LF) measurements of caries, using the DIAGNOdent
(KaVo, Biberach, Germany), has been assessed in several
in vitro studies. It appears that all types of sealants effect LF
detection of carious lesions. When a pigment powder was
used as the fluorescent signal source, opaque sealants reduced
the LF signal strength to a greater extent than clear sealants.11
Other studies where LF measurements were obtained from
teeth with carious lesions demonstrate the same trend that
both clear and opaque sealants interfere with the ability of LF
devices to detect caries with opaque sealants having a greater
effect.12–15 Although these studies demonstrated variable
reductions (or small increases in the case of clear sealants)
in LF readings following sealant application, they did not
examine the effect of sealants on the diagnostic performance
of this device in correctly identifying teeth with enamel and
dentine lesions. When the accuracy of the LF device’s
determination of a tooth’s caries diagnosis was verified by
histological examination of the teeth, clear sealants were
observed to have a modest adverse effect on the sensitivity of
LF-detection.16,17 In contrast, the application of opaque
sealants to the occlusal surface resulted in a considerable
loss of detection sensitivity.18 A similar trend, showing the
preservation of diagnostic sensitivity following clear sealant
application and loss of sensitivity in opaque sealant treated
teeth was observed in a study where occlusal caries was
detected using optical coherence tomography.19 Taken to-
gether, these studies highlight the difficulties encountered in
detecting occlusal caries in sealed teeth particularly when
opaque sealants are used. The results of these studies indicate
that it may be possible to use certain caries detectors to
monitor teeth with clear sealants for signs of lesion progres-
sion.
The SpectraTM (Air Techniques, Melville, New York) is a
recently introduced fluorescence camera (FC) caries detection
device that detects both enamel and dentine lesions. This
591
device is equivalent to the VistaProof caries detector (Dürr
Dental AG, Bietigheim-Bissingen, Germany). The FC handpiece
emits a violet-blue light at a wavelength of 405 nm. This light
stimulates porphyrins from cariogenic bacteria to fluoresce
red and healthy tooth structure to fluoresce green. This FC
images alterations in the tooth’s intrinsic fluorescence as a
means of detecting enamel demineralisation and bacterially
derived fluorescence arising in carious dentine. When inter-
faced with a computer, the tooth’s fluorescent image can be
stored along with numerical values based on the fluorescence
and compared to images and readings obtained at subsequent
examinations.
In an in vitro study performed on third molars that were
either caries free or had small occlusal lesions,20 FC-based
caries diagnosis was compared to clinical assessment using
the ICDAS (International Caries Detection and Assessment
System)21 and radiographic methods. In this study, a histo-
logical assessment of each tooth’s caries status was per-
formed. This allowed the sensitivity and specificity of each
diagnostic method in determining the presence of enamel and
dentine caries to be calculated. The results of this study
indicated that the Spectra’s performance in detecting both
enamel and dentine lesions was superior to radiographic
diagnosis and comparable to visual diagnosis using ICDAS
criteria. The results of this study agree with other in vitro
studies, examining occlusal caries in permanent molars,
undertaken with the VistaProof caries detector. In addition
to having satisfactory sensitivity and specificity, FC measure-
ments also show good reproducibility with studies demon-
strating high levels of intra and inter-examiner measurement
agreement.22–26 In a clinical study where the true caries status
of the teeth was unknown, a positive correlation was observed
between readings made with various caries detector devices,
including the FC and the ICDAS scores of the teeth.27 When the
clinical accuracy of FC and LF devices were compared against a
histological determination of the tooth’s caries status made
following extraction, the LF was judged to be more accurate
than the FC. Both devices were judged to be adjuncts to visual
examination.28 Analysis of results of both in vitro and clinical
evaluations of the FC device indicate that the manufacturer-
suggested diagnostic thresholds used for the detection of
enamel and dentine lesions are not optimal and that adjusting
these cut-offs could improve diagnostic performance.23,26,28,29
To date, no studies have evaluated the effectiveness of FC
devices in detecting caries under commonly used pit and
fissure sealants. The purpose of this study was to assess the
effect of sealant placement on FC readings obtained from teeth
where the clinical examination indicated early caries. In one
part of the study, the effect of clear and opaque sealant
placement on the FC readings obtained from extracted teeth
was determined. The presence and extent of caries in these
teeth was verified by histological examination of these teeth
following removal of the occlusal surface. By employing a
‘‘gold standard’’ histological determination of each tooth’s
caries diagnosis we could determine the impact of sealant
placement on the sensitivity and specificity of the FC’s
diagnostic performance. In a second part of the study, FC
readings were obtained from children’s permanent molars
prior to and following the application of clear sealants. In this
clinical portion of the study, the selection criteria and protocol
592 journal of dentistry 41 (2013) 590–599
for sealant application used at our institution was followed.
We determined if sealant placement caused a significant
change in the FC’s ability to accurately assess early non-
cavitated, carious lesions. The goal of this study was to
determine if FCs can be used to assess early caries in sealed
teeth and monitor sealed teeth for evidence of caries
progression.
2. Materials and methods
2.1. Tooth selection for the in vitro study
An in vitro study was performed using 31 extracted human
third molar teeth. Adult patients having third molar extrac-
tions at New Jersey Dental School’s Oral Surgery clinic
consented to donate their extracted teeth for research
projects. The University’s Institutional Review Board approved
the tooth collection procedure (Protocol number 0120050074).
Following extraction, teeth were debrided of adherent hard
and soft tissues then stored in 1% phenol. Teeth were used
within one month of collection.
Since the goal of the study was to determine if sealant
application altered the FC readings obtained from teeth with
small occlusal lesions, only teeth with visual evidence of early
occclusal caries were selected for this study. The inclusion
criteria for the extracted teeth used, was based on the
International Caries Detection and Assessment System
(ICDAS).21 Teeth needed to have areas of the pits and fissures
lesions classified as ICDAS code 2 or 3 (having distinct colour
change present when wet and possible local enamel break-
down but without shadow in the underlying dentine) in order
to be included in the study. ICDAS scoring of the occulsal
surfaces was performed by two investigators (DR and KM)
according to the published criteria. In instances where
discrepancies existed between the two scores these were
resolved by joint examination.
2.2. Fluorescent camera use
In vitro tooth examinations using the Spectra FC device was
conducted as described previously.20 The FC measurements
were performed on a damp occlusal surface and repeated on
each tooth three times in order to assess the reproducibility of
the measurements. The FC unit’s handpiece with a 10 mm
spacer was placed on the occlusal surface of each molar and
an image for each tooth was collected as per the manufac-
ture’s instructions. The FC handpiece was connected to a
computer operating Air Technique’s Visix1 image analysis
software. The laptop screen displayed a colour map of the
tooth’s occlusal surface, which displayed severity of caries
using a numerical scale (Table 1). A training and calibration
exercise was held where the two examiners (DR and KM)
obtained FC readings from a group of 10 teeth that included
teeth in both ICDAS categories used in this study. By using a
uniform method of positioning the FC handpiece with respect
to the occlusal surface the two examiners were able to
generate equivalent colour maps indicating agreement
interms of diagnostic category, with peak FC readings which
disagreed by no more than 0.2.
Table 1 – Fluorescent camera (Spectra Caries Detection
Aid) image colour code and numerical vales.
Colour Numerical values Interpretation
Green 0.0–0.9 Sound enamel
Blue 1.0–1.4 Initial caries on enamel surface
Red 1.5–1.9 Enamel caries up to the dentino-
enamel junction
Orange 2.0–2.4 Dentine caries
Yellow 2.5 Deep dentine caries
2.3. Experimental procedure
Each tooth was assigned an identification number. Data
regarding each tooth’s ICDAS scores and FC readings were
entered onto a database in such a manner that the
experimenter did not have access to that tooth’s previous
readings.
After the baseline measurements, the samples were
cleaned with flower of pumice slurry on a prophylaxis-cup
using a slow speed handpiece. Following that, a second
measurement was performed with the FC to evaluate if this
cleaning procedure altered the FC readings. Digital photo-
graphs were made for each tooth (Canon, USA Lake Success,
NY, USA). The teeth were then randomly assigned to an
experimental group where teeth were sealed with one of the
following four sealants:
1 Group one: Shofu1 ClearCheck (nanofilled) (Shofu Dental
Corporation, San Marcos, CA, USA), a clear sealant.
2 Group two: Delton1 unfilled sealant (Dentsply International,
York, PA, USA), a clear sealant.
3 Group three: Clinpro1 Sealant (3M ESPE1, St. Paul, MN, USA),
an opaque sealant.
4 Group four: Delton1 FS 55% filled sealant (DENTSPLY
International, York, PA, USA), an opaque sealant.
Teeth in all groups were then etched with 37% phosphoric
acid (gel) for the time recommended by the sealant manufac-
turer, rinsed with water and dried. The sealants were placed
on each tooth and light-cured as per manufacture’s instruc-
tions. After the sealants were placed, the teeth were stored in a
humid atmosphere for less than 6 h and a second visual
examination was performed where the teeth were scored
using the ICDAS, photographed and then the FC measure-
ments were repeated a third time. This post-sealant visual/FC
examination was performed by one examiner who was
blinded to the exact type of sealant used and initial values
measured for that tooth. The presence of a clear or opaque
sealant was however obvious when the post-sealant exam-
inations were performed.
Following the post-sealant ICDAS/FC evaluation, a histo-
logical evaluation was performed on each tooth to assess if
caries was present and its extent using the method described
previously.20 The occlusal surface of each tooth was removed.
Cuts were made perpendicular to the long axis of the tooth to
expose tissue at the base of the occlusal fissures using a slow
speed saw (Isomet1, Buehler LTD., Lake Bluff, IL, USA) with a
diamond blade and water lubrication. Care was taken to
expose the maximum extent of caries. After the tooth was
 journal of dentistry 41 (2013) 590–599
sectioned a histological visual evaluation was performed and
the cut surface of the tooth was photographed. Inspection of
the magnified image of the cut teeth on a computer screen
verified the histological diagnosis. Teeth were characterised as
having intact pits and fissures, having white areas of enamel
demineralisation without dentine staining or having areas of
brown staining of the dentine, indicative of dentine caries.
2.4. Clinical study
Thirteen children (6 males, 7 females) ages 6–11 participated in
this single visit study the protocol of which was approved by
the University’s Institutional Review Board (Protocol number
2012001155). Written parental consent and subject assent was
obtained prior to performing the study procedures. Patients at
our institution’s Pediatric Dentistry clinic requiring one or
more sealants on permanent molars were given the opportu-
nity to participate. At our clinic most patients with molars
lacking cavitated lesions are offered occlusal sealants.
Following examination and treatment planning as per clinic
protocol, 42 teeth were examined with the FC using the 10 mm
spacer and infection control sleeve as described in the
manufacturer’s instructions. Images and readings from the
selected teeth were processed and stored on a laptop
computer using the Visix software. Three images were
collected for each tooth to insure reproducibility. One
investigator (DP) who was responsible for the patient’s
treatment performed the FC readings. Next the occusal
surface was cleaned with a toothbrush,30 etched and sealed
with Delton clear sealant, applied according to the manufac-
turer’s instructions. Following sealant application, a second
FC image was obtained for the sealed tooth. This post-sealant
FC image was obtained approximately 10 min following
sealant application during which time the child sat in the
dental chair with his or her mouth closed.
2.5. Data analysis
For both studies each tooth’s peak FC reading was recorded.
The peak FC reading for teeth in the various experimental
groups was expressed as means  standard deviation. For the
in vitro study, a one-way analysis of variance (ANOVA) was
used to determine whether the pre-sealant FC values of the
teeth in the four groups were statistically different from one
another. A paired two-tailed t-test was used to compare the
baseline FC readings of all the teeth used, with that obtained
following cleaning of the teeth with pumice. A paired two-
tailed t-test was also performed to determine whether teeth in
each group experienced significant changes in FC reading
following sealant application. Based on preliminary experi-
ments a sample size of at least seven teeth was selected based
on a statistical power of 0.8 in resolving meaningful
differences in FC readings (0.35) following sealant application.
A reduction in FC readings of this magnitude would be likely to
result in a change in a tooth’s diagnostic category.
Using each tooth’s histological score as a gold-standard
indication of the extent of caries involvement, the impact of
sealants application on the sensitivity and specificity of the FC
and visual examination in detecting dentine caries was
assessed.31 For this analysis, an ICDAS score of 3 (localised
593
enamel breakdown) was used as a clinical indication of a
lesion extending into dentine.21 A FC reading of 2 was, as
specified by the manufacturer, us used as a cut off for dentine
caries. Sensitivity and specificity values were calculated and
displayed with 95% confidence intervals. Statistical signifi-
cance was set at the 0.05 level. In order to determine if a
significant difference existed between the pre and post-
sealant FC readings in the clinical study, a paired 2-tailed t-
test was performed. An un-paired t-test was performed to
determine if the teeth in the in vitro study had significantly
different FC readings than teeth in the clinical study. Data was
analyzed using JMP1 statistical software (SAS Institute Inc.,
Cary, NC, USA). Statistical significance was set at p < 0.05.
3. Results
3.1. In vitro study
At baseline the mean peak FC reading for the sample of 31
teeth was 1.93  0.37. A second FC reading was performed
after all of the teeth were cleaned with pumice. Following
pumice cleaning, the mean peak FC reading was 1.94  0.32. A
paired t-test shows that cleaning the teeth with pumice did not
cause a significant change in FC reading ( p = 0.7).
The mean pre-sealant FC reading was 1.83  0.34 in the
Delton unfilled group, 1.83  0.45 in the Delton FS 55% filled
sealant group, 2.2  0.36 in the Shofu ClearCheck and
1.85  0.22 in 3M ESPE Clinpro sealant group. A one-way
ANOVA showed that there was no statistically significant
difference in the mean peak FC readings of the four groups at
baseline ( p = 0.13).
Photos and FC images of a maxillary molar sealed with
Shofu ClearCheck, a clear sealant, are shown in Fig. 1.
Comparisons of the pre and post-sealant photographs
(Fig. 1a and c) reveal that the occlusal lesion can be seen
through this sealant. The pre and post sealant FC images
(Fig. 1b and d) are also similar with both having a peak reading
of 2.1, indicating dentine caries. The mean peak FC reading for
teeth treated with Shofu ClearCheck (n = 8) was 2.2  0.36 at
baseline and 1.98  0.45 after sealant application. Application
of this sealant resulted in a 10% reduction in the peak FC
readings measured from these teeth. This reduction failed to
reach statistical significance ( p = 0.05) (Table 2).
Following application of Delton unfilled sealant the tooth’s
FC image is similar to the image obtained from the tooth prior
to sealant application (not shown). In the group of teeth (n = 8)
sealed with Delton unfilled the mean peak FC reading was
1.83  0.34 at baseline, and 1.68  0.26 after sealant applica-
tion an 8.2% reduction (Table 2). A paired t-test showed that
this was a statistically significant reduction in FC measure-
ments ( p = 0.009).
Fig. 2 shows pre and post sealant photographs and FC
images taken of a mandibular molar sealed with 3M ESPE
Clinpro, an opaque sealant. Although the areas of caries are
not visible on the post sealant photograph (Fig. 2c), they are
discernible on the FC image obtained following application of
the sealant (Fig. 2d). There was however, a reduction in the
peak FC reading from 2.0 to 1.5. The 7 teeth sealed with 3M
ESPE Clinpro had a baseline FC reading of 1.85  0.22 that
594 journal of dentistry 41 (2013) 590–599

Fig. 1 – Photos (a and c) and FC images (b and c) of an extracted maxillary molar with small areas of non-cavitated occlusal
caries taken before (a and b) and following (c and d) application of a clear sealant (Shofu ClearCheck). Notice the effect of
sealant application on the two areas where the FC indicates dentine caries (readings I2).

declined 16.2% to 1.55  0.28 after sealant application (Table 2).
A paired t-test for the 3M ESPE1 Clinpro sealant group showed
a statistically significant reduction between the FC peak
reading at baseline and those measured after the placement of
the sealant ( p = 0.008).
As was observed in teeth sealed with Clinpro, application of
a second opaque sealant, Delton FS 55% left areas of caries are
still visible on the post-sealant FC image (not shown). In
contrast, these same caries areas are not visible on the post-
sealant photograph. The mean peak FC value of the teeth in
Delton FS 55% filled sealant group (n = 8) was 1.83  0.45 at
baseline and 1.45  0.27 following application of the sealant.
Overall application of Delton1 FS 55% resulted in a 20.8%
reduction in the peak FC reading (Table 2). A paired t-test

Table 2 – Effect of sealant application on peak FC readings (mean W standard deviation) obtained from teeth in vitro.
Sealant Type N Pre-sealant FC reading Post-sealant FC reading FC reading % change p-value
Shofu Clear Check Clear 8 2.2  0.36 1.98  0.45 10 0.05
Delton unfilled Clear 8 1.83  0.34 1.68  0.26 8.2 0.009
3M ESPE Clinpro Opaque 7 1.85  0.22 1.55  0.28 16.2 0.008
Delton FS 55% Opaque 8 1.83  0.45 1.45  0.27 20.8 0.002
 journal of dentistry 41 (2013) 590–599 595

Fig. 2 – Photo (a and c) and FC images (b and c) of an extracted mandibular molar with a small area of non-cavitated occlusal
caries taken before (a and b) and following (c and d) application of an opaque sealant (3M ESPE Clinpro sealant).
Comparisons of the pre and post-sealant photographs show that the lesion is no longer visually detectable. In contrast, the
lesion can still be seen on the post-sealant FC image. There was however, a reduction in the FC readings following sealant
application.

comparing the pre and post sealant FC scores showed a
statistically significant difference between the baseline FC
measurements and the reading measured following place-
ment of the sealant ( p = 0.002).
Comparison of pre and post sealant FC images indicates
that the areas in the post-sealant photos where fluorescence
differs from healthy tooth structure are restricted to the areas
of altered fluorescence in the pre-sealant images.
The results of the histological evaluations confirmed the
presence of carious lesions in all the teeth included in the
study. Of the 31 teeth examined, 11 (35%) had enamel lesions,
and 20 (65%) had dentine lesions.
3.2. Effect of in vitro sealant application on the diagnostic
performance of the FC and ICDAS scoring
The impact of sealant placement on the sensitivity and
specificity of visual examination and the FC is shown in Table
3. Since all teeth used in this study had histologically verified
enamel or dentine caries the effect of sealant placement on
the detection of dentine caries was assessed. Prior to sealant
application visual examination detected dentine caries with a
sensitivity of 0.65 and a specificity of 0.82. Following clear
sealant application the sensitivity of visual examination
dropped insignificantly to 0.54 and the specificity increased
to 1. Prior to sealant application the FC was able to detect
dentine caries with a sensitivity of 0.6 and a specificity of 0.73.
Following clear sealant application the sensitivity was 0.55
and the specificity increased to 0.8 this was not a significant
change in either parameter. Following the application of
opaque sealants it was not possible to perform visual caries
assessment. Opaque sealant application had a large impact on
the FC’s diagnostic performance. All of the five teeth that had
pre-sealant FC readings (2) indicative of dentine caries had
post-sealant readings that were below the cut-off for dentine
caries diagnosis. The post-opaque sealant sensitivity was 0
and the post-sealant specificity was 1. These values were
significantly different from the pre-sealant sensitivity and
specificity.
3.3. Clinical study
Base line and post-Delton unfilled sealant application FC
readings were obtained from 19 maxillary and 23 mandibular
596 journal of dentistry 41 (2013) 590–599

Table 3 – Impact of sealant placement on the diagnostic performance of visual examination and the FC. The sensitivity
and specificity of visual examination and the FC in detecting dentine caries was calculated for teeth prior to and following
placement of clear or opaque sealants. Following placement of clear sealants there was a modest drop in the sensitivity of
both methods. Opaque sealants preclude visual examination and abolished the sensitivity of the FC in detecting dentine
caries.
Sensitivity 95% confidence interval Specificity 95% confidence interval
Visual detection without sealants 0.65 0.41–0.84 0.82 0.48–0.97
FC without sealants 0.6 0.36–0.8 0.73 0.39–0.93
Visual detection with clear sealants 0.54 0.25–0.82 1 0.46–1
FC with clear sealants 0.55 0.25–0.82 0.8 0.3–1
FC with opaque sealants 0 0–0.37 1 0.46–1

first permanent molars. The mean FC pre-sealant reading
obtained from these teeth is 1.49  0.19. This value was
significantly lower than the mean FC reading obtained for the
teeth in the in vitro study ( p < 0.01). The peak pre-sealant FC
readings of 41 of the teeth examined indicated enamel caries.
One tooth had a FC reading of 2 indicating dentine caries.
Following cleaning of the occlusal surface, etching and
application of Delton Clear sealant the mean FC reading fell
to 1.43 a 4.01% reduction that was statistically significant
( p < 0.01). A pre-sealant FC image of a maxillary molar is
shown in Fig. 3a. For this tooth, the peak FC reading was 2.0
indicating possible dentine caries. Following placement of
Delton Clear sealant the peak FC value of the tooth did not
change (Fig. 3b).

4. Discussion

Pit and fissure sealants have been shown to be an effective

Fig. 3 – FC images of the occusal surface of a patient’s
maxillary molar taken before (a) and following (b), the
placement of a clear sealant (Delton Clear). Both images
indicate areas of enamel demineralisation as well as an
area with a FC reading of 2 indicating possible dentine
caries. In the case of this tooth, the peak FC reading was
unaffected by the sealant placement. The small bar at the
upper left of both images was placed to hide the patient’s
identity.
means of preventing the formation of occlusal carious
lesions.3 Many teeth slated to be sealed may however, have
small lesions that either escape clinical detection or are judged
by the clinician to be treatable with sealants.32 Despite the
effectiveness of sealants in preventing and arresting caries
they are not totally effective.9 In view of the possibility of
caries progression in sealed teeth various diagnostic methods
have been evaluated for their ability to detect and assess the
severity of carious lesions in sealed teeth. The goal of this
research, including this study, is to determine the suitability of
diagnostic methods for the longitudinal monitoring of sealed
teeth for signs of caries progression. Previous assessments of
the effect of sealant application on the ability of clinical
examination methods and caries detectors to detect non-
cavitated lesions have shown that the presence of sealants
impact diagnostic performance.10 Opaque sealants have a
greater effect than clear sealants.11–19 In LF studies, some
sealants cause the LF readings obtained from teeth to increase
slightly, this was attributed to the auto-fluorescence of some
sealant material.13
FC systems allow non-cavitated carious lesions to be
visualised and numerically assessed for severity. Like other
caries detectors, the FC can act as an adjunct to the clinical
diagnosis of occlusal caries.28 In order to examine the
suitability of a FC device in detecting and monitoring carious
lesions in sealed teeth we examined the effect of sealant
application on FC readings obtained from extracted third
molars and from permanent first molars in paediatric
patients. In determining the impact of sealant placement on
FC readings, each tooth acted as its own control since readings
were obtained before and following sealant application. In
both studies, we reported the effect of sealant application on
each tooth’s peak FC reading since this measurement would
be most important in influencing a clinician’s treatment
decision.
 journal of dentistry 41 (2013) 590–599
In the clinical study, we followed the patient selection
procedure and material choice criteria used in our institution’s
Pediatric Dentistry clinic. In or clinic, teeth lacking obvious
visual signs of caries are treated with Delton Clear sealant. The
teeth examined in the clinical study had significantly lower FC
scores than the teeth used in the in vitro study, indicating less
advanced lesions. In the in vitro study we selected teeth with
ICDAS scores of 2 or 3. Selection of teeth with this limited
range of caries severity was done so that we could test the
effect of sealant placement on FC diagnosis in teeth with
lesions that were detectable by visual examination but that
lacked evident cavitation extending into dentine. The litera-
ture supports the use of sealants over lesions that are non-
cavitated but visually detectable as areas of colour change.32
Teeth are typically cleaned with pumice prior to sealing.
Certain pumice-containing pastes interfere with LF device
measurements.33 The results of this study showed that there
was no statistically significant difference of the peak FC
readings before and after cleaning the teeth with pumice.
Although the effects of other pastes used in pre-sealant
cleaning need to be tested, these results indicate that pumice
cleaning does not interfere with FC caries detection.
Following application of sealants to extracted teeth there
was a decreased in the FC readings when compared with the
baseline measurements. Clear sealant application (Delton
unfilled and Shofu ClearCheck) resulted in lower reductions
than that observed following application of the opaque
sealants (Delton1 FS 55% and Clinpro). The reduction in FC
readings resulting from sealant application was significant for
all sealants tested except Shofu ClearCheck. In the clinical
portion of the study, we also observed a small but significant
reduction in FC readings when Delton unfilled sealant was
applied.
All sealants apparently attenuate the transmission of light
to some degree with opaque sealants having a greater effect. It
is likely that these effects apply to, the violet-blue wavelengths
of light used by the FC and light originating in the fluorescence
of tooth structure and bacterial pigments. The FC images
indicate that the sealants themselves do not fluoresce. The FC
image of fissures that were free of carious alterations did not
change when sealant material was placed in those fissures.
In the in vitro study we used each tooth’s histological
determination of caries presence and severity as a gold
standard against which we judged whether the FC correctly or
incorrectly rated a tooth as having dentine caries or not. Since
all of the teeth used in this study had enamel or dentine
lesions we could not examined the sensitivity or specificity of
the FC in detecting enamel lesions as was done in our previous
study.20 We compared the sensitivity and specificity determi-
nations made prior to sealant application to those made post-
sealant in order to ascertain the impact of sealant application
on the FC’s diagnostic performance. As was observed in our
previous study,20 the FC has comparable sensitivity and
specificity to visual examination in detecting dentine lesions.
The application of clear sealant caused a small, insignificant
drop in the sensitivity of both the FC and visual assessment.
An increase in the specificity of both methods of caries
detection was observed following clear sealant application.
Both the sensitivity decrease and the specificity increase are
like the reduction in mean FC reading; indications that clear
597
sealants reduce light transmission between the FC and tooth
structure.
In contrast to what was observed in clear sealant treated
teeth, opaque sealant application caused a loss of sensitivity
and made visual caries assessment impossible. These results
are consistent with findings obtained when the impact of
sealant application on the performance of other caries
detection devices was evaluated.11,18,19 The results of this
study indicate that FCs can be used to assess non-cavitated
lesions on teeth treated with clear sealants and suggest that
the FC can be used in longitudinal studies to examine sealed
teeth for signs of lesion progression. It would be of interest to
determine the suitability of FCs and other caries detectors in
assessing and monitoring early lesions treated by other non-
invasive methods.34
In this study the sensitivity and specificity calculations
were based on the manufacturer’s suggested cut-off for
dentine caries (2). Dentists employing FCs to make clinical
decisions may use this value. Data from several in vitro studies
were analyzed to determine if better cut-offs could be found
that optimised the instrument’s diagnostic performance.
These studies indicate that a dentine caries threshold of less
than 2 would be more accurate.28
Although there was considerable loss of FC signal strength
and sensitivity following opaque sealant application, the
outline and appearance of the carious lesion was still apparent
on FC images obtained after opaque sealant application. The
light scattering effect of the particulates in the opaque sealant
does not apparently prevent the instrument’s blue-violet light
from reaching the tooth or all fluorescent emissions generated
by the tooth from returning to the instrument. This finding
raises the possibility that it may be possible to use FCs to
monitor teeth with opaque sealants for indications of caries
progression. The FC images of teeth with opaque sealants
must, however, be interpreted with caution since the sealant
particle’s selective filtering of certain wavelengths may
obscure fluorescent emissions from some types of carious
lesions.35 Experiments utilising teeth with more advanced
lesions, than the ones used in this study, may help to
determine if the FC can detect extensive lesions through
opaque sealants. If this is the case, it may be possible to use the
FC to detect the enlargement of lesions beneath opaque
sealants.
Teeth in children and adolescents with non-cavitated
occlusal dark lesions have a higher tendency to develop
cavitated lesions than teeth with normally coloured occlusal
fissures.36,37 This was found to be particularly true in
adolescence with a prior history of caries.36 At risk teeth in
individuals with high caries risk should be sealed and
monitored for signs of lesion progression. FC readings taken
from un-sealed teeth at the initial examination can aid in
caries diagnosis and in making the decision to apply
sealants.28,32
The results of this study suggest that the FC along with
visual examination can be used to monitor teeth with clear
sealants for signs of lesion progression. Since a small but
statistically significant drop in FC readings brought about by
clear sealant application was observed in the clinical portion
of the study, the baseline FC reading to be used for longitudinal
monitoring should be taken following sealant placement.
598 journal of dentistry 41 (2013) 590–599
Since the clinical portion of our study measured immediate
changes in FC readings obtained following sealant placement,
longitudinal studies are needed to determine the usefulness of
the FC as an adjunct to clinical exam in helping dental
professionals monitor sealed teeth for caries progression. We
anticipate that the images generated by the FC will facilitate
the monitoring of sealed teeth over time by giving the dentist a
detailed view with numerical values, of the occlusal lesion
against which changes can be assessed. During monitoring an
increase in FC readings, particularly changes that indicate a
transition from enamel to dentine caries (readings 2) would
warrant further investigation. The use of the FC and other
devices to monitor sealed teeth should permit clinicians to
confidently use sealants to manage early occlusal lesions; and
when combined with other methods of caries risk assessment,
practice less invasive dentistry.38,39
During our clinical study we noticed that the FC images
were a useful aid in educating parents and patients about the
incipient tooth lesions that necessitate sealant placement.
Limitations on the use of the FC in studies where repeated
measurements of the same tooth are made include factors
that affect the instrument’s consistent placement such as the
loss or eruption of adjacent teeth since these changes may
interfere with generating follow up images that are compara-
ble to those obtained at baseline.
5. Conclusions
The Spectra Caries Detection Aid is a useful tool to detect
caries beneath clear pit and fissure sealants.
Non-cavitated occlusal lesions can be imaged on teeth
sealed with opaque sealants, however, it was not possible to
accurately assess the severity of these lesions.
Acknowledgement
The authors thank Air Techniques for donating the Spectra
Caries Detector and for providing technical assistance. We
thank Dr. Milton Houpt for valuable advice, David Furgang for
assistance with the statistical analysis and Daniel Dinowitz for
assistance in collecting the clinical data. We thank the NJDS
Department of Pediatric Dentistry for financial support.
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