Caries-preventive effect of fissure sealants: a systematic review

Indications for fissure sealants and their role in children and adolescents

The aim of this article is to summarize and interpret present knowledge and evidence on the effect of fissure sealing permanent first and second molars in children and adolescents with two commonly used materials: resin sealants and glass ionomer sealants. Also, to identify important gaps in our knowledge. The results show that the conclusions from systematic reviews differ in several aspects, and that important knowledge gaps still exist, such as the costs and benefits of sealing low- versus high-risk populations. The effect of sealing noncavitated caries lesions is uncertain and possible differences in effect between resin sealants and the high viscosity glass ionomers need to be investigated.

Laser fluorescence of dentin caries covered with a novel nano-filled sealant

The aim of the present study was to assess the possibility to measure caries-induced laser fluorescence underneath a novel nano-filled fissure sealant. Sixty freshly extracted human teeth with occlusal dentine carious lesions were horizontally divided, exposing the respective lesion. Teeth were randomly assigned to three groups: (I) white fissure sealant with filler particles (Fissurit F, Voco), (II) clear fissure sealant without filler particles (Fissurit, Voco) and (III) novel experimental fissure sealant with nano-filler particles (Voco). Starting with a sealant thickness of 3 mm, laser fluorescence measurements (DIAGNOdent, KaVo) were performed after finishing the sealant surfaces with polishing papers, reducing the material at intervals of 0.5 mm until the sealant was removed completely. Evaluating a thickness of 0.5 mm, both the clear (83 % of the baseline fluorescence after fine grit polishing) and the white sealant (25 %) did not allow to measure baseline fluorescence (p < 0.05) with no fluorescence reduction in the experimental sealant group (p > 0.05). With increasing sealer thickness, fluorescence was influenced even by the experimental material (89 % of the baseline value at 1 mm). However, by using the experimental material, statistically significant higher fluorescence values than those for the other materials under study (p < 0.05) were obtained. Thicker sealant layers and coarse grit polishing caused a decrease of laser fluorescence in all groups (p < 0.05). Employing the experimental nano-filled sealant, laser fluorescence measurements for caries detection can be performed through thicker sealant layers compared to conventional sealant materials. Thus, it might be possible to use this material to assess a caries progression underneath the sealant and administer an appropriate therapy in due time.

Advances in pediatric dentistry

This article addresses advances in 4 key areas related to pediatric dentistry: (1) caries detection tools, (2) early interventions to arrest disease progression, (3) caries-risk assessment tools, and (4) trends in pediatric procedures and dental materials.

Therapeutic effect of glass-ionomers: an overview of evidence

The requirements for an ideal restorative material include adhesion to tooth structure (enamel and dentine) and an ability to withstand the traumas of occlusion. However, some level of an anticaries effect is also desirable. After a long history of glass-ionomer cement (GIC) development, an evidence base in support of the therapeutic effect of GIC, particularly with regard to its anticaries effect, is emerging. This evidence is increasingly presented through systematic reviews of clinical GIC application and, to a certain extent, relates to a caries-preventive effect of the material itself. However, the strength of evidence supporting other aspects of GIC, such as a higher remineralizing effect, fluoride uptake in hard tooth tissue and fluoride release of GIC, is limited. Nevertheless, the results of these in situ and laboratory trials provide valuable insights into factors that facilitate understanding of the clinical efficacy of GIC.

Caries-preventive effect of resin-modified glass-ionomer cement (RM-GIC) versus composite resin: a quantitative systematic review

AIM

To determine whether resin-modified glass-ionomer cement (RM-GIC), when compared with composite resins (CR), offers a significant caries-preventive effect.

STUDY DESIGN

Quantitative systematic review.

METHODS

Five databases were searched until 29 July 2010. Inclusion criteria were: relevant to review question related to orthodontic or restorative treatment; published in English; prospective clinical 2-arm study. Exclusion criteria were: no computable data reported; study groups not followed up in the same way. References of included articles were checked. The outcome measure was absence of carious lesions. Dichotomous datasets for both groups were extracted from accepted trials. Trials were assessed for selection-, detection/performance, attrition and publication bias.

RESULTS

Of the 11 trials included, 6 were accepted and 24 datasets extracted; 17 datasets showed no difference after 4 weeks to >25 months. There were 7 datasets that favoured (p < 0.05) RM-GIC after 12 - 24 months. The results are limited by risk of selection-, detection-/performance bias and attrition bias. Risk of publication bias was identified.

CONCLUSIONS

The overall results showed either no difference between the materials, or indicated that RM-GIC has a superior caries-preventive effect. The clinical meaning of this result remains uncertain due to risk of bias. High-quality randomised control trials are needed in order to answer the review question conclusively.

Sealing occlusal caries lesions in adults referred for restorative treatment: 2-3 years of follow-up

The aim of this study was to assess the possibility to arrest occlusal caries lesions in adults by sealant as well as to assess the presence of radiographic progression, arrest, and regression of the sealed lesions. Seventy-two occlusal caries lesions in 52 adult patients referred to restorative treatment by senior lecturers at School of Dentistry, Copenhagen, Denmark were included. In case the patient had more than one occlusal caries lesion, randomization between sealing and restoration was made; otherwise, the lesion was sealed. In total, 60 resin sealants and 12 composite restorations were made. Follow-up period was 25-38 months (mean = 33 months). Data were analyzed using non-parametric statistics including kappa statistics. After 2-3 years, the dropout rate was 15%; two patients did not show up for control and nine previously sealed lesions were restored by the patients' general practitioners. All 12 restorations and 39 of the remaining 49 sealants were well functioning, seven (14%) sealants were repaired/replaced due to failure, and three (6%) sealed lesions were restored due to caries progression (p > 0.05). The radiographic assessment showed caries progression beneath five (10%) sealants, caries regression beneath one (2%) sealant, and unchanged depth beneath 43 (88%) sealants and all restorations (p > 0.05). The majority of the referred lesions were successfully arrested by sealants, indicating the possibility for extending the criteria for sealing occlusal caries lesions in adults. However, a longer observation period is needed for final conclusion. Extending the criteria of therapeutic sealing of occlusal caries lesions in adults will lead to increased dental health.

Wear and morphology of infiltrated white spot lesions

OBJECTIVES

To evaluate the toothbrush wear resistance of infiltrated artificial white spot lesions following two infiltration strategies, and to assess their ultramorphology.

METHODS

Flat enamel surfaces from freshly extracted bovine teeth were polished and immersed in a Buskes demineralising solution for 30 days to create incipient caries-like lesions (white spots). Two experimental regions on the surface of each tooth were infiltrated with an infiltrant and a commercial etch-and-rinse adhesive. Toothbrush abrasion was applied for 20,000 cycles. Vertical wear loss of the infiltrated areas was measured after 10,000 and 20,000 cycles against unabraded and abraded enamel using confocal laser scanning microscopy (CLSM; multiple t-tests, α=0.05). Each lesion's surface and cross-section were evaluated under CLSM and scanning electron microscopy after etching and infiltration to assess ultramorphology.

RESULTS

After 20,000 abrasion cycles, a statistically non-significant difference in vertical wear loss was measured for the infiltrant versus the adhesive compared with the original enamel (42.6±20.7 μm vs. 40.4±18.5 μm, p>0.05). Irregular surface profiles were common for the adhesive-infiltrated group as a result of peeling and blistering of the resin-covering layer. Ultramorphology of the infiltrated lesions revealed different patterns of penetration regarding density and depth.

CONCLUSIONS

Although both infiltration strategies had equivalent wear resistance to toothbrush abrasion, surface and morphological aspects pointed to improved surface stability and infiltration quality for the infiltrant material.

Use of caries prevention services in the Northwest PRECEDENT dental network

OBJECTIVE

This cross-sectional study assessed the use of caries preventive services by Northwest PRECEDENT dental network practitioners and compared the caries experience of patients who received such services in the past 12 months with those who had not.

METHODS

An oral health survey was conducted on approximately 20 patients seen by each of 97 private practice dental practitioners in the network. Eligible patients (total of 1877 aged 3-92) were randomly assessed for the occurrence of one or more new caries lesions as well as having received the following preventive services within the past 12 months: fluoride varnish or gel, sealant in molar or premolar, and prophylaxis. Patients were stratified by gender and age (1-17 years old, 18-64 years old, and 65+ years old). Logistic regression was used to investigate the association between the practitioner characteristics and the use of preventive services, as well as the preventive services and the presence of a new caries lesion in the past 12 months.

RESULTS

The percent of patients in age category 1-17 years old/18-64 years old/65+ years old receiving each preventive treatment varied as follows: 95%/85%/81% for prophylaxis, 87%/24%/22% for fluoride, and 27%/2%/0% for sealant. There was a very limited association between the use of a specific preventive service and practitioner gender, and no significant association between use of services and practice location (rural, urban or suburban). There was a significant association between greater use of sealants for dentists with 0-15 years of practice experience as compared with those having more than 25 years of experience. For the 1-17-year-old age group, boys had about 1.7 times the odds of having a new lesion than girls in the past 12 months, and patients receiving a sealant had 1.9 times the odds of having a new caries lesion. In the 18-64-year-old group, receiving a prophylaxis in the past 12 months was significantly associated with lower odds for having a new lesion (odds ratio = 0.57).

CONCLUSIONS

This study reports that aside from prophylaxis, which more than 85% of the patients had received, about one-third of the patients overall received preventive services consisting of either sealants or some type of fluoride treatment in private dental practices in the Northwest PRECEDENT network.

Caries-preventive effect of glass ionomer and resin-based fissure sealants on permanent teeth: An update of systematic review evidence

Background

This article constitutes a partial update of the original systematic review evidence by Yengopal et al. from 15 January 2008 (published in the Journal of Oral Science in 2009) with primary focus on research quality in regard to bias risk in trials. Its aim is to update the existing systematic review evidence from the English literature as to whether caries occurrence on pits and fissures of teeth sealed with either GIC or resin is the same.

Methods

In addition to the 12 trials included during the original systematic review, 5 new trials were identified during the database search (up to 26 August 2010) and 2 further trials were included from a hand search and reference check. Of these, 3 trials were excluded and 16 were accepted for data extraction and quality assessment. The quality of accepted trials was assessed, using updated quality criteria, and the risk of bias was investigated in more depth than previously reported. In addition, the focus of quantitative synthesis was shifted to single datasets that were extracted from the accepted trials.

Results

Twenty-six dichotomous and 4 continuous datasets were extracted. Meta-analysis and cumulative meta-analysis were used in combining clinically homogenous datasets. The overall outcome of the computed datasets suggest no difference between the caries-preventive effects of GIC- and resin-based fissure sealants.

Conclusions

This overall outcome is in agreement with the conclusions of the original systematic review. Although the findings of the trials identified in this update may be considered to be less affected by attrition- and publication bias, their risk of selection- and detection-/performance bias is high. Thus, verification of the currently available results requires further high quality randomised control trials.

General practitioners' use of caries-preventive agents in adult patients versus pediatric patients: findings from the dental practice-based research network

BACKGROUND

In this study, the authors tested the frequency of dentists' recommendations for and use of caries-preventive agents for children as compared with adults.

METHODS

The authors surveyed 467 general dentists in the Dental Practice-Based Research Network who practice within the United States and treat both pediatric and adult patients. They asked dentists to identify the percentage of their patients for whom they had administered or recommended dental sealants, in-office and at-home fluoride, chlorhexidine rinse and xylitol gum.

RESULTS

Dentists were less likely to provide adult patients than pediatric patients with in-office caries-preventive agents. However, the rate at which they recommended at-home preventive regimens for the two groups of patients was similar. Dentists with a conservative approach to caries treatment were the most likely to use and recommend the use of caries-preventive agents at similar rates in adults as in children. In addition, dentists in practices with a greater number of patients who had dental insurance were significantly more likely to provide in-office fluoride or sealants to adult patients than to pediatric patients.

CONCLUSION

General dentists use in-office caries-preventive agents more commonly with their pediatric patients than with their adult patients.

PRACTICE IMPLICATIONS

General dentists should consider providing additional in-office caries-preventive agents for their adult patients who are at increased risk of experiencing dental caries.

Resin-modified glass-ionomer cements versus resin-based materials as fissure sealants: a meta-analysis of clinical trials

AIM

To appraise quantitatively current evidence regarding the caries-preventing effect of resin-modified glass-ionomer cement (RM-GIC) fissure sealants in comparison to that of resin-based fissure sealants.

STUDY DESIGN

Systematic review with meta-analysis.

METHODS

8 Anglophone databases and 2 Lusophone databases were searched until 15 April 2009, using a pre-determined search strategy. Clinical trials were considered for inclusion if their titles/abstracts were relevant to the topic, published in English, Portuguese or Spanish and had a two-arm longitudinal study design. The outcome measure of the caries-preventive effect was caries absence on sealed teeth. Two reviewers independently extracted data from the accepted articles in order to complete a 2x2 table for meta-analysis. The unit of interest was the tooth, and the number of caries-free teeth (n) at the end of each time interval (6, 12 and 24 months) was compared against the total number of evaluated teeth (N).

STATISTICS

Datasets were assessed for their clinical and methodological heterogeneity, following Cochrane guidelines, and only homogeneous datasets were combined for meta-analysis, using a random effects model (RevMan 4.2). Differences in the caries-preventive effect were computed on the basis of the combined Relative Risk (RR) with 95% confidence interval (CI).

RESULTS

Of the 212 articles identified, only 6 trials were included. From these, 19 separate datasets were extracted. For the pooled data, equivalent caries-preventive effects were observed at 6 months (RR= 0.98, 95% CI 0.95- 1.00; p = 0.08); 12 months (RR=1.00, 95% CI 0.96-1.04, p = 0.99) and 24 months (RR=1.01, 95% CI 0.84-1.21, p = 0.91). The 36-month data (not pooled) favoured resin-based sealants (RR 0.93, 95% CI 0.88-0.97, p = 0.002).

CONCLUSIONS

This meta-analysis found no conclusive evidence that either material was superior to the other in preventing dental caries.

UK National Clinical Guidelines in Paediatric Dentistry: Use of fissure sealants including management of the stained fissure in first permanent molars

International Journal of Paediatric Dentistry 2010 Summary.  The process of guideline production began in 1994, resulting in first publication in 1997. Each guideline has been circulated to all Consultants in Paediatric Dentistry in the UK, to the Council of the British Society of Paediatric Dentistry (BSPD), and to people of related specialties recognised to have expertise in the subject. The final version of the guideline is produced from a combination of this input and thorough review of the published literature. The intention is to encourage improvement in clinical practice and to stimulate research and clinical audit in areas where scientific evidence is inadequate. Evidence underlying recommendations is scored according to the SIGN classification and guidelines should be read in this context. For those wishing further detail, the process of guideline production in the UK is described in the International Journal of Paediatric Dentistry 1997; 7: 267-268. This guideline is an update on the previously published BSPD policy document on fissure sealants. (Nunn et al., Int J Paed Dent 2000; 10: 174-177).

Fissure sealant retention and caries development after resealing on first permanent molars of children with low, moderate and high caries risk

AIM

This was to evaluate the retention of fissure sealants (FS) and their effectiveness after resealing on caries reduction applied to first permanent molars, in a sample of children stratified according to their caries risk status in a private practice setting.

METHODS

The sample was 1,274 FS applied on first permanent molars (FPM) of 380 children (6 to 8 years old). Follow-up and monitoring for resealing was 3 years after FS placement, having at least one recall visit per year. Caries risk was based on baseline dmft index: low (dmft=0), moderate (dmft=1-4), high (dmft >4), with almost half of the teeth belonging to the high-risk group. All sealed teeth were evaluated and recorded for FS failure and resealing in case of partial/total loss, as well as caries development. Survival analysis using the Cox Proportional Hazards regression model was used for data evaluation.

RESULTS

Of the 1,274 sealed surfaces, 927 (72.8%) needed no intervention 185 (14.5%) needed only resealing and 162 (12.7%) developed caries during the study. Of 162 carious surfaces, 107/ 675 (15.9%) were from the high caries risk children, compared with 17/144 (11.8%) and 38/455 (8.3%) from the moderate and low caries risk group respectively. The highest number of failures, 4.9% and resealing were found at first recall, declining to 1.4% at the end of the study. Development of caries followed a steady rate of 6-8% per year. Cox proportional hazards model indicated, regardless if resealing or caries development was considered a failure or resealing was a success and caries development a failure, only the high dmft index appeared in both cases to significantly increase the chance (158% and 173% respectively) of FS failure and caries development compared with moderate and low dmft index. Other variables when inserted into the hazard model, such as age, sex and number of visits, either did not show a significant effect or only marginally affected FS retention, without modifying the association between caries risk and sealant failure.

CONCLUSIONS

Children of a high baseline caries risk status showed lower FS retention rates and higher occlusal caries prevalence following FS loss compared with those of moderate and low risk status. Resealing does not seem to dramatically change the final outcome of the higher risk group to develop more caries, necessitating other more effective measures to increase the retention of FS on these highly vulnerable areas.

Pit and fissure sealants versus fluoride varnishes for preventing dental decay in children and adolescents

BACKGROUND

The majority of the detected increment in dental caries among children and adolescents is confined to pit and fissure surfaces of first molars.

OBJECTIVES

The objective of this study was to compare the effectiveness of pit and fissure sealants with fluoride varnishes in the prevention of dental decay on occlusal surfaces.

SEARCH STRATEGY

The Cochrane Oral Health Group's Trials Register, CENTRAL, MEDLINE, EMBASE and 10 other databases were searched to November 2009. There were no language or publication restrictions.

SELECTION CRITERIA

Random or quasi-random allocation study design; sealants versus fluoride varnish or sealants and fluoride varnish combination versus fluoride varnish alone; and subjects under 20 years of age. The primary outcome of interest was the increment in the numbers of carious occlusal surfaces of permanent premolars and molars.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results, extracted data and assessed the risk of bias of trials. Risk ratios (RR) were calculated for differences between intervention and control groups and in split-mouth studies for differences of paired tooth surfaces being carious or not. No data could be combined or meta-analyses undertaken due to the clinical and methodological diversity between study designs.

MAIN RESULTS

Four studies were eligible for inclusion in the review. Results of one split-mouth study at low risk of bias and one cluster randomised study at moderate/high risk of bias revealed the effectiveness of pit and fissure sealants to be statistically significantly higher than an application of fluoride varnish every 6 months in preventing occlusal decays of first molars at 23 months (with a RR of 0.74, 95% confidence interval (CI) 0.58 to 0.95); and at 4 years and 9 years (with a RR of 0.42, 95% CI 0.21 to 0.84 and RR of 0.48, 95% CI 0.29 to 0.79, respectively). One small parallel group study at moderate/high risk of bias failed to find a difference between sealants and fluoride varnishes. Further, one split-mouth study at low risk of bias with 24 months of follow-up found significantly more caries on the fluoride varnished tooth surfaces, compared to sealed plus fluoride varnished surfaces, with a RR of 0.36 (95% CI 0.21 to 0.61).

AUTHORS' CONCLUSIONS

There was some evidence on the superiority of pit and fissure sealants over fluoride varnish application in the prevention of occlusal decays. However, current scarce data limit recommendations on whether to apply pit and fissure sealants or fluoride varnishes on occlusal surfaces.

Caries-preventive effect of glass ionomer and resin-based fissure sealants on permanent teeth: a meta analysis

The purpose of this quantitative systematic review was to appraise the evidence on the caries-preventive effect of glass ionomer cement (GIC) in relation to resin-based fissure sealants. Nine English and two Portuguese databases were searched (15 January 2008). Randomized clinical trials and systematic reviews were considered for inclusion. Trial exclusion criteria were: drop-out rates > 33%; no randomization; baseline differences in groups not statistically adjusted; and no clinically important outcomes were presented. Two authors reviewed the articles independently. The outcome measure for the caries preventive effect was caries absence on sealed teeth. Of the 112 identified articles, 25 were selected for review. Of these, 14 were excluded and 11 accepted (8 trials; 3 systematic reviews). The accepted reviews provided no evidence of superiority of either sealant material. Six trials were included for meta-analysis. The pooled odds ratio was 0.96, 95% CI 0.62-1.49, indicating no difference in the caries-preventive effect of GIC and resin-based fissure sealant material. This systematic review with meta-analysis found no evidence that either material was superior to the other in the prevention of dental caries. Thus, both materials appear equally suitable for clinical application as a fissure sealant material.

Long-term performance of resin based fissure sealants placed in a general dental practice

OBJECTIVES

The aim of the present retrospective study was to evaluate the long-term performance of resin based fissure sealants applied in a general dental practice.

METHODS

Regularly attending patients visiting the practice between July 2006 until November 2007 and who had received sealants before 1st of January 2000 were included in the study. Date of placement of a sealant in posterior non-discoloured permanent teeth and replacement by a restoration was recorded. In a clinical examination occlusal surfaces were scored for (partial) sealant loss and fissure discolouration. The restoration profile of the patient was assessed as low or high, based on the number of restorations placed per year since the first sealant. Sealants had been applied by four dentists and a dental hygienist.

RESULTS

1204 sealants were placed in 148 patients. After a mean follow-up time of 11.6 years, 41.3% of placed sealants were still fully retained and 11.4% were replaced by a restoration. Failure rates were significantly higher in high than in low restoration profile patients and in molars compared to premolars. In those fissures with lost or partially lost sealants, discolouration frequently occurred (40% of all surfaces) irrespective of restoration profile of the patient.

CONCLUSIONS

In this retrospective practice based study, long-term performance of sealants depended on restoration profile of the individual patient and the tooth type (molar versus premolar).

Dental fillings for the treatment of caries in the primary dentition

BACKGROUND

Childhood caries (tooth decay) consists of a form of tooth decay that affects the milk teeth (also known as baby or primary teeth) of children. This may range from tooth decay in a single tooth to rampant caries affecting all the teeth in the mouth. Primary teeth in young children are vital to their development and every effort should be made to retain these teeth for as long as is possible. Dental fillings or restorations have been used as an intervention to repair these damaged teeth. Oral health professionals need to make astute decisions about the type of restorative (filling) material they choose to best manage their patients with childhood caries. This decision is by no means an easy one as remarkable advances in dental restorative materials over the last 10 years has seen the introduction of a multitude of different filling materials claiming to provide the best performance in terms of durability, aesthetics, symptom relief, etc when placed in the mouth. This review sought to compare the different types of dental materials against each other for the same outcomes.

OBJECTIVES

The objective of this review was to compare the outcomes (including pain relief, survival and aesthetics) for restorative materials used to treat caries in the primary dentition in children. Additionally, the restoration of teeth was compared with extraction and no treatment.

SEARCH STRATEGY

Electronic searches of the following databases were undertaken: the Cochrane Oral Health Group's Trials Register (up to January 2009); CENTRAL (The Cochrane Library 2009, Issue1); MEDLINE (1966 to January 2009); EMBASE (1996 to January 2009); SIGLE (1976 to 2004); and conference proceedings on early childhood caries, restorative materials for paediatric dentistry, and material sciences conferences for dental materials used for children's dentistry (1990 to 2008). The searches attempted to identify all relevant studies irrespective of language.Additionally, the reference lists from articles of eligible papers were searched, handsearching of key journals was undertaken, and personal communication with authors and manufacturers of dental materials was initiated to increase the pool of suitable trials (both published and unpublished) for inclusion into this review.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-randomised controlled trials with a minimum period of 6 months follow up were included. Both parallel group and split-mouth study designs were considered. The unit of randomisation could be the individual, group (school, school class, etc), tooth or tooth pair. Included studies had a drop-out rate of less than 30%. The eligible trials consisted of young children (children less than 12 years) with tooth decay involving at least one tooth in the primary dentition which was symptomatic or symptom free at the start of the study.

DATA COLLECTION AND ANALYSIS

Data were independently extracted, in duplicate, by two review authors. Disagreements were resolved by consultation with a third review author. Authors were contacted for missing or unclear information regarding randomisation, allocation sequence, presentation of data, etc. A quality assessment of included trials was undertaken. The Cochrane Collaboration statistical guidelines were followed for data analysis.

MAIN RESULTS

Only three studies were included in this review. The Fuks 1999 study assessed the clinical performance of aesthetic crowns versus conventional stainless steel crowns in 11 children who had at least two mandibular primary molars that required a crown restoration. The outcomes assessed at 6 months included gingival health (odds ratio (OR) 0.3; 95% confidence interval (CI) 0.01 to 8.32), restoration failure (OR 3.29; 95% CI 0.12 to 89.81), occlusion, proximal contact and marginal integrity. The odds ratios for occlusion, proximal contact and marginal integrity could not be estimated as no events were recorded at the 6-month evaluation. The Donly 1999 split-mouth study compared a resin-modified glass ionomer (Vitremer) with amalgam over a 36-month period. Forty pairs of Class II restorations were placed in 40 patients (21 males; 19 females; mean age 8 years +/- 1.17; age range 6 to 9 years). Although the study period was 3 years (36 months), only the 6- and 12-month results are reported due to the loss to follow up of patients being greater than 30% for the 24- and 36-month data. Marks 1999a recruited 30 patients (age range 4 to 9 years; mean age 6.7 years, standard deviation 2.3) with one pair of primary molars that required a Class II restoration. The materials tested were Dyract (compomer) and Tytin (amalgam). Loss to follow up at 24 and 36 months was 20% and 43% respectively. This meant that only the 24-month data were useable. For all of the outcomes compared in all three studies, there were no significant differences in clinical performance between the materials tested.No studies were found that compared restorations versus extractions or no treatment as an intervention in children with childhood caries.

AUTHORS' CONCLUSIONS

It was disappointing that only three trials that compared three different types of materials were suitable for inclusion into this review. There were no significant differences found in all three trials for all of the outcomes assessed. Well designed, randomised controlled trials comparing the different types of filling materials for similar outcomes are urgently needed in dentistry. There was insufficient evidence from the three included trials to make any recommendations about which filling material to use.

Improved Resin Infiltration of Natural Caries Lesions

In artificial lesions, improved penetration and the caries-inhibiting properties of infiltrating resins could be observed with increasing penetration coefficients (PCs). The aim of the present study was to compare the penetration abilities of an experimental ‘infiltrant’ into natural lesions with those of an adhesive in vitro. Extracted human molars and premolars showing proximal white spots were cut across the lesions perpendicular to the surface. Corresponding lesion halves were etched for 120 sec with 15% hydrochloric acid gel and were subsequently treated with either an adhesive (PC: 31 cm/sec) or an infiltrant (PC: 273 cm/sec). Specimens were observed by confocal microscopy and transverse microradiography. Penetration depths of the adhesive were significantly lower compared with those of the infiltrant (p < 0.001; Wilcoxon). It can be concluded that resins with higher PCs (infiltrants) show superior ability to penetrate natural lesions compared with resins with lower PCs.

Pit and fissure sealants for preventing dental decay in the permanent teeth of children and adolescents

BACKGROUND

Although pit and fissure sealants are effective in preventing caries, their efficacy may be related to the caries prevalence in the population.

OBJECTIVES

The primary objective of this review was to evaluate the caries prevention of pit and fissure sealants in children and adolescents.

SEARCH STRATEGY

We searched the Cochrane Oral Health Group Trials Register, CENTRAL (The Cochrane Library 2007, Issue 3) and MEDLINE (to October 2007); EMBASE (to June 2007); SCISEARCH, CAplus, INSPEC, NTIS, PASCAL, DARE, NHS EED and HTA (to February 2008). There were no language or publication restrictions.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials of at least 12 months in duration comparing sealants with no sealant or sealants from different classes of materials for preventing occlusal caries in children and adolescents under 20 years. The primary outcome was the increment in the numbers of carious occlusal surfaces of premolars and molars.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results, extracted data and quality assessed trials. Risk ratios (RR) were calculated for differences between intervention and control groups and in split-mouth studies for differences of paired tooth surfaces being carious or not. The meta-analyses were conducted using a random-effects model.

MAIN RESULTS

Sixteen studies were included in the review; 7 studies provided data for comparison of sealant versus control without sealant and 10 studies for comparison of sealant versus sealant. Five split-mouth studies and one parallel group study with 5 to 10 year old children found a significant difference in favour of second or third generation resin-based sealants on first permanent molars, compared to a control without sealant, with a pooled RR of 0.13 (95% confidence interval (CI) 0.09 to 0.20), 0.22 (95% CI 0.15 to 0.34), 0.30 (95% CI 0.22 to 0.40), and 0.40 (95% CI 0.31 to 0.51) at 12, 24, 36 and 48-54 months follow up, respectively. Further, one of those studies with 9 years of follow up found significantly more caries in the control group compared to resin sealant group; 27% of sealed surfaces were decayed compared to 77% of surfaces without sealant.The results of the studies comparing different sealant materials were conflicting.

AUTHORS' CONCLUSIONS

Sealing is a recommended procedure to prevent caries of the occlusal surfaces of permanent molars. The effectiveness of sealants is obvious at high caries risk but information on the benefits of sealing specific to different caries risks is lacking.

Can caries fissures be sealed as adequately as sound fissures?

Sealing caries fissures is considered an appropriate treatment option for arresting the caries process. However, little information is available regarding the sealing of occlusal cavitated dentin lesions. The hypothesis tested in this in vitro study was that no difference in microleakage and sealant penetration depth exists between cavitated and sound sealed fissures when a resin is used. Eighty molars, each with an occlusal cavitated dentin lesion, were treated according to 5 experimental protocols and compared with a control group of sealed sound molars. In the experimental groups, fissure sealants were placed with and without an adhesive, and in various ways. All teeth were sectioned, and microleakage and sealant penetration into the fissure were evaluated. Sealed caries fissures showed significantly more microleakage and insufficient sealant penetration depth than sound fissures. Neither the use of an adhesive nor its intermediate curing influenced the microleakage score and the penetration ability of sealants.

Exploring four-handed delivery and retention of resin-based sealants

BACKGROUND

To date, no trials have been published that examine whether four-handed delivery of dental sealants increases their retention and effectiveness. In the absence of comparative studies, the authors used available data to explore the likelihood that four-handed delivery increased sealant retention.

METHODS

The authors examined data regarding the retention of autopolymerized resin-based sealants from studies included in systematic reviews of sealant effectiveness. The explanatory variable of primary interest was the presence of a second operator. To examine the unique contribution of four-handed delivery to sealant retention, the authors used linear regression models.

RESULTS

Eleven of the 36 studies from systematic reviews met explicit criteria and were included in this analysis. The high level of heterogeneity among studies suggested that multivariate analysis was the correct approach. According to the regression model, the presence of a second operator increased retention by 9 percentage points.

CONCLUSIONS

For this group of studies, four-handed delivery of autopolymerized sealants was associated with increased sealant retention.

CLINICAL IMPLICATIONS

Using four-handed delivery to place resin-based sealants may increase retention.

Comparison of the effectiveness of fissure sealants in Finland, Sweden, and Greece

OBJECTIVE

To evaluate the effectiveness of sealant treatment in preventing dental restorations due to caries in a practice-based research network in Finland, Sweden, and Greece.

MATERIAL AND METHODS

Times of tooth emergence, sealing treatment, and dental caries were compiled from the dental charts of 4735 subjects born in 1970-72 in Finland and in 1980-82 in Finland, Sweden, and Greece. Survival time between tooth emergence and placement of first restoration was measured and estimated using survival analysis methodology.

RESULTS

At the end of follow-up (7-10+ years), 30-40% of sealed molars and 60-80% of non-sealed molars were restored. Early sealant placement compared to late sealing did not result in significantly higher survival of 1st molars. The strategy of sealing the 1st molars only in high caries risk subjects was as effective as sealing all the molars and premolars routinely without caries risk determination.

CONCLUSIONS

The sealing of all molar fissures proved to be no more effective than sealing risk fissures of subjects. Early sealing did not result in any better outcome than late sealing. The effectiveness of sealant treatment in preventing dental restorations is dependent on the caries risk of individuals and caries prevalence of the country.

Caries management: technical solutions to biological problems or evidence-based care?

Caries-related clinical decision-making remains a centrepiece of clinical dentistry. However, the oral disease patterns are rapidly changing towards the better among major sections of the populations, most notably in the high-income countries. The caries decline is well documented among children and younger adults, and is gradually seen to trickle into middle and old age as well. Although it is tempting for the dental profession to take the credit for this development, the evidence points in a different direction. The major contribution of dentistry seems primarily related to changes in the treatment philosophies towards a less interventionist approach. This review aims to spur a further change in the diagnostic and treatment criteria used in the management of dental caries for the benefit of the oral health status of our patients. We must come to terms with the fact that our traditional core skills, our manual dexterity and technical competence, have less to offer to oral health than we have been accustomed to think. The dental schools and the professional dental organizations must carry the responsibility for promoting the necessary changes in the caries related clinical decision-making strategies to allow practicing dentists to provide appropriate oral health care to our populations.

Effects of composite fissure sealants on IR laser fluorescence measurements

The influence of composite fissure sealants on caries detection with IR laser fluorescence measurements should be assessed. Thirty-five extracted human teeth with 105 initial carious lesions were included. Six groups containing 15 lesions each were sealed with either a clear or a white version of three sealants. Group 7 was sealed with an experimental nanofilled material. Occlusal surfaces were irradiated by a diode laser (<1 mW, 655 nm). Fluorescence was measured before and after acid etching, directly and 1 week after application of the sealants. Values significantly increased after etching (p < 0.05). Compared to initial measurements, values decreased after sealing with the white materials (p < 0.05). There was no difference between values before and after sealing with the clear and the experimental materials (p > 0.05). All values were reproducible. The study indicates that it might be possible to monitor caries activity under clear or nanofilled fissure sealants by means of laser fluorescence.

Defectos del esmalte, caries en dentición primaria, fuentes de fluoruro y su relación con caries en dientes permanentes

OBJECTIVE

To examine the relationship between the presence of enamel defects, dental caries in primary teeth, and exposure to various fluoride technologies and the presence of dental caries in permanent teeth in children with mixed dentition.

MATERIALS AND METHODS

A cross-sectional study was conducted in 713 children aged 6-9 years old in 4 elementary schools in Campeche, Mexico through the use of a questionnaire for the mothers and an oral examination in the children. The dependent variable was the prevalence of caries in permanent dentition.

RESULTS

The mean number of decay, missing or filling teeth in primary dentition (dmft) and in permanent dentition (DMFT) was 2.48 (2.82) (deft > 0 = 58.9%) and 0.40 (0.98) (DMFT > 0 = 18.2%), respectively. The significant caries index (SiC), which is calculated in deciduous dentition, was 5.85 for 6 year-olds. Multivariate logistic regression adjusted for variables related to fluoride exposure revealed that older age (OR = 2.99), a deft of > 0 (OR = 5.46), and lower maternal educational level (OR = 1.57) were significantly associated with a higher number of dental caries in permanent teeth. An interaction between sex and enamel defects was also found.

CONCLUSIONS

The number of dental caries in both primary and permanent dentitions was relatively smaller than that found in prior studies performed in Mexican populations. The results confirm that the presence of caries in primary dentition is strongly associated with caries in permanent dentition. No significant relationship was found between fluoride exposure and dental caries in permanent dentition.

Influence of pH and oxygen-inhibited layer on fluoride release properties of fluoride sealant

OBJECTIVES

This study tested the hypothesis that the oxygen-inhibited layer on a light-cured methacrylate based resin and the pH of the storage medium would increase significantly the initial fluoride release and long-term release rate from fluoride dental sealant.

METHODS

Forty-eight discs (16-mm diameter x 1-mm thick) were made from FluroShield (<5 wt% NaF) and Helioseal F (<30 wt% fluorosilicate glass) sealants. For each sealant, 24 discs were cured through a Mylar strip that covered the surface and the remaining 24 discs were cured in air allowing formation of the oxygen-inhibited surface. Each specimen in the 24-disc groups was stored individually in 25-mL vials, and divided into four six-vial groups to receive 10 mL of pH4-pH7 (designation of pH 4-7) lactate buffer solutions. The buffer solutions were replaced periodically up to 121 days. The cumulative fluoride release over time was used to determine the coefficients for short-term and long-term release.

RESULTS

Two-way ANOVA showed that the mean coefficient values for either sealant were significantly influenced by the curing condition (p<0.0001) and pH (p<0.0001), except for short-term release from NaF sealant. The duration of short-term release was much longer for the fluorosilicate glass sealant.

CONCLUSIONS

Both pH and the source of fluoride source incorporated in the sealant play significant roles in fluoride release.

Caries-preventive effect of resin-based and glass ionomer sealants over time: a systematic review

INTRODUCTION

The difference in preventing dentine lesion development between resin-based and glass ionomer sealant materials is unclear. Two recently published reviews were unable to conclude on the difference because the comparison was an exclusion criterion in one review and there were statistical shortcomings in the relevant papers in the other (Cochrane) review.

OBJECTIVES

The aim of the present investigation was to carry out a systematic review on the caries-preventive effect of these two types of sealant materials under more liberal exclusion criteria concerning the statistical presentations in the publications.

METHODS

Based on five exclusion criteria, the literature search in the electronic libraries PubMed and MEDLINE and the publications retrieved in the Cochrane review, revealed 12 eligible publications for analyses. A variety of glass ionomers and resin-based sealant materials had been applied in the included studies. Attributable risk (AR) was chosen rather than relative risk (RR), as used in the Cochrane review, because RR is very instable in a low caries population.

RESULTS

There was no consistent pattern observed with respect to the caries-preventive effect of either resin-based or glass ionomer sealants. Therefore, it was impossible to calculate an overall AR.

CONCLUSIONS

There is no evidence that either resin-based or glass ionomer sealant material is superior to the other in preventing dentine lesion development in pits and fissures over time.

Which sealant system should I use?

DATA SOURCES

As well as using Medline, Embase and the Cochrane library to source studies, a search was made by hand of reference lists of the selected articles and dental conference proceedings, and experts were contacted to identify any unpublished research, irrespective of language in each case.

STUDY SELECTION

Two reviewers independently selected the studies. The latter were chosen if randomised, quasi-randomised or controlled clinical trials that used split-mouth design or were parallel group studies, and which compared different available resin-based sealants (RBS) on permanent molars or compared different clinical protocols for the same RBS. Studies comparing RBS with ultraviolet-activated sealants, glass ionomer cements (GIC) or resin-reinforced GIC sealants were not considered and neither were resins indicated for restoration, except for flowable resins.

DATA EXTRACTION AND SYNTHESIS

Data was extracted by two reviewers independently. Data synthesis was conducted using the program RevMan (version 4.2; Cochrane Collaboration, Dublin, Ireland). Relative risks (RR) were calculated because the outcome was a dichotomous variable; variance was expressed using 95% confidence intervals (CI). Meta-analysis was carried out if the studies were homogeneous enough and subgroup analyses were conducted if necessary. The heterogeneity of the results was assessed using chi-squared tests, and sensitivity analyses were performed excluding unpublished studies or poor-quality studies.

RESULTS

A total of 31 studies met the inclusion criteria. Sixteen studies compared two different types of RBS, those that were light-cured (LRBS) or auto-polymerised (ARBS), with fluoride-containing sealants (FRBS). Seventy-five per cent were split-mouth design studies. Seven studies compared LRBS with ARBS and nine studies compared LRBS with FRBS. The retention rate of ARBS and LRBS did not differ significantly. LRBS had a significantly higher retention rate than FRBS at 48 months (RR, 0.80; 95% CI, 0.72-0.89). Only 15 studies of limited quality focused on the best clinical protocol to adopt for sealant application.

CONCLUSIONS

Only FRBS had a lower retention rate than ARBS or LRBS. This review did not allow the best clinical procedure to be determined because of insufficient studies. Well-designed randomised clinical trials are still needed that focus on sealant retention and consider different clinical procedures, particularly new enamel preparation techniques such as air-abrasion or sono-abrasion.

Retention of resin-based pit and fissure sealants: A systematic review

The aim of the present study was to perform a systematic review on the retention of resin-based sealants (RBSs) according to the material used and the clinical procedure. An electronic search in MEDLINE, EMBASE, Cochrane library and SCOPUS was completed by a hand search in conference proceedings. One hundred and twenty-four studies were identified, 31 of which were included. The retention rate of auto-polymerized and light-cured RBSs did not differ significantly. Light-cured RBSs had a significantly higher retention rate than fluoride-containing light-cured RBSs at 48 months (RR = 0.80, 95% CI: 0.72-0.89) and more. Concerning the clinical procedure, the scarcity of well-conducted studies made judgement difficult, except for the isolation stage. If using a rubber dam did not affect retention of auto-polymerized RBSs, it did for fluoride-containing light-cured RBSs (RR = 2.03, 95% CI: 1.51-2.73).

Performance of a Conventional Sealant and a Flowable Composite on Minimally Invasive Prepared Fissures

Preparation prior to fissure sealing did not enhance the performance of the sealant. However, if caries is suspected and an enameloplasty has to be performed, opening the fissure with a diamond bur and sealing it with a conventional sealer is recommended.

Sealant and fluoride varnish in caries: a randomized trial

Little is known about the effect of discontinuation of sealant or fluoride varnish. The purpose of this study was to compare sealant with fluoride varnish in the prevention of occlusal caries in permanent first molars of children over a nine-year period: 4 yrs for program evaluation plus 5 yrs of discontinuation. A clinical trial was conducted on three groups of six- to eight-year-old schoolchildren: a control group (n = 45); a group (n = 37) in which sealant was applied and reapplied up to 36 mos; and a group (n = 38) in which fluoride varnish was applied and re-applied up to 42 mos. Percent caries reduction was studied in these initially healthy molars with complete occlusal eruption: 129 (control), 113 (sealant), and 129 (varnish) molars met inclusion criteria. Of these, 76.7%, 26.6%, and 55.8% had developed occlusal caries at 9 yrs, which implies caries reductions of 65.4% (SE = 8.5%) for sealants vs. control and 27.3% (SE = 10.2%) for varnish vs. control. Furthermore, the varnish program was not effective during the discontinuation period.