Form - Pit & Fissure Sealant Worksheet

Pit & Fissure Sealant Worksheet

Please add your name in the form below exactly as it appears on your ID

First Name

Last Name

Date

Laboratory Typodont

Laboratory Patient – Must be submitted/completed twice, once for every patient

Clinical Patient – Must be submitted/completed twice, once for every patient

Tooth Number

Patient #

Patient’s Full Name

Patient #

Patient’s Full Name

Use this worksheet to identify errors in procedures. Place a check mark in the box each time a step in the procedure is incorrectly performed or omitted.

*In some cases, a specific procedural step that is identified by an asterisk will require that this step must be correctly performed as improper performance would cause harm to the patient and/or cause failure to the sealant.

Infection Control/ Patient Safety

1. Apply barriers to chair, unit, light, air/water syringe, hoses, HVE, saliva ejector, handpiece*

2. Don PPE: gloves, mask, gown, scrubs, eye wear, patient safety glasses*

3. Check medical health history.

Assemble Armamentaria

1. Basic set-up: mirror, explorer, cotton pliers

2. Air-water syringe tip, HVE tip, saliva ejector

3. Low-speed handpiece with disposable prophy angle

4. Non-fluoridated/flavored prophy paste

5. Isolator cotton roll holder, Ori-aids, Dri-tips, Lingua-fix

6. Etchant, sealant material, applicator tips and brushes

7. Curing light, tinted safety glasses or shield.

8. Articulating paper, composite finishing stone, floss

Tooth Preparation

1. Remove plaque/pellicle from tooth/teeth with non-fluoridated/flavored prophy paste and rubber cup.*

2. Rinse surface and suction. Check the surface with an explorer for complete pumice removal. Rinse again and thoroughly dry.

3. Use articulating paper and determine the occlusal stops.

4. Isolate quadrant area with appropriate cotton rolls, holder, Dri-Aid, Ori-angle etc.

5. Completely dry teeth.

Etchant Placement

1. Place etchant onto enamel surfaces to be sealed; extending beyond the anticipated sealant area with etchant, but not extending onto the inclines or ridges. *

2. Allow etchant solution to remain for 15 seconds.

3. Thoroughly rinse removing etchant, while keeping teeth isolated. If teeth become contaminated, re-etch for 10 seconds, and rinse again.

4. Thoroughly rinse tooth surfaces for at least 20-30 seconds followed by dyeing for 20 seconds.

5. Etchant pattern will not appear on typodont tooth.

Sealant Placement and Curing

1. Express small drop of UltraSeal XT plus at the end

2. Express another small drop; lightly paint on until desired amount is reached. Sealant materials appear thin. Once in place sealant will thicken.

3. Polymerized sealant by curing light. Hold light as close to the surface as possible without touching materials (1-2mm). Standard curing light-cure for 20 seconds; high energy curing light-cure for 10 seconds.

4. Check the void area, bubbles, etc. with an explorer. If sealant needs to be added and the surface is still not contaminated, add sealant and cure. If the surface is contaminated, repeat etchant for 10 seconds, rinse, dry.

5. Using a dampened cotton roll, gently remove the inhibition layer from the sealant surface.

6. Remove isolation materials, rinse and dry.

7. Check contact with floss.

8. Check occlusion with articulating paper

9. Reduce any high areas on the sealant with composite stone.

Infection Control-Patient Safety Clean-Up

1. Remove barriers on the chair, unit, light, air/water syringe, hose, HVE, saliva ejector, headpiece.

2. Surface disinfect areas that are not covered with barriers

3. Prepare and institute sterilization procedures

4. Manage PPE: gloves, masks, scrubs, eyewear, patient safety glasses.

Instructor Evaluation:

Instructors Name

Date / Time

Use this worksheet to identify errors in procedures. Place a check mark in the box each time a step in the procedure is incorrectly performed or omitted.

Infection Control / Patient Safety

1. Apply barriers to chair, unit, light, air/water syringe, hoses, HVE, saliva ejector, handpiece*

2. Don PPE: gloves, mask, gown, scrubs, eye wear, patient safety glasses*

3. Check medical health history.

Comments

Assemble Armamentaria

1. Basic set-up: mirror, explorer, cotton pliers

2. Air-water syringe tip, HVE tip, saliva ejector

3. Low-speed handpiece with disposable prophy angle

4. Non-fluoridated/flavored prophy paste

5. Isolator cotton roll holder, Ori-aids, Dri-tips, Lingua-fix

6. Etchant, sealant material, applicator tips and brushes

7. Curing light, tinted safety glasses or shield.

8. Articulating paper, composite finishing stone, floss

Comments

Tooth Preparation

1. Remove plaque/pellicle from tooth/teeth with non-fluoridated/flavored prophy paste and rubber cup.*

2. Rinse surface and suction. Check the surface with an explorer for complete pumice removal. Rinse again and thoroughly dry.

3. Use articulating paper and determine the occlusal stops.

4. Isolate quadrant area with appropriate cotton rolls, holder, Dri-Aid, Ori-angle etc.

5. Completely dry teeth. *

Comments

Etchant Placement

1. Place etchant onto enamel surfaces to be sealed; extending beyond the anticipated sealant area with etchant, but not extending onto the inclines or ridges. *

2. Allow etchant solution to remain for 15 seconds.

3. Thoroughly rinse removing etchant, while keeping teeth isolated. If teeth become contaminated, re-etch for 10 seconds, and rinse again.

4. Thoroughly rinse tooth surfaces for at least 20-30 seconds followed by dyeing for 20 seconds.

5. Etchant pattern will not appear on typodont tooth.

Comments

Sealant Placement and Curing

1. Express small drop ofUltraSeal XT plus at the end

2. Express another small drop; lightly paint on until desired amount is reached. Sealant materials appear thin. Once in place sealant will thicken.

5. Using a dampened cotton roll, gently remove the inhibition layer from the sealant surface.

6. Remove isolation materials, rinse and dry.

7. Check contact with floss.

8. Check occlusion with articulating paper

9. Reduce any high areas on the sealant with composite stone.

Comment

Infection Control-Patient Safety Clean-Up

1. Remove barriers on the chair, unit, light, air/water syringe, hose, HVE, saliva ejector, headpiece.

2. Surface disinfect areas that are not covered with barriers

3. Prepare and institute sterilization procedures

4. Manage PPE: gloves, masks, scrubs, eyewear, patient safety glasses.

Comments on the work done

I the student, confirm that all the procedures are performed correctly.

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Form - Pit & Fissure Sealant Worksheet

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