Clinical effectiveness and cost-effectiveness of fissure sealants in children and adolescents with a high caries risk

The effectiveness of completely and incompletely sealed first permanent molars on caries prevention

Fissure sealants are effective caries preventive measure. However, a dilemma has been expressed more than once, whether incompletely sealed fissures provides sufficient protection against caries. Dental examinations were performed in 88 children, aged 8 and then 4 years later at 12 years. All first permanent molars (FPMs), as diagnosed at the age of 8, were divided into three groups: nonsealed, incompletely and completely sealed. Four years later caries incidence and changes in presence and quality of fissure sealant were analyzed. At the age of 8 and 12 mean DMFT were 0.73 ± 1.24 and 3.48 ± 3.04, respectively. 71.59% of the 8‐year‐olds and 78.41% of the 12‐year‐olds had at least one sealed FPM. At the age of 8, 154 FPMs were completely sealed and 42 FPMs were incompletely sealed. Four years later, 81.17%, 71.43% and 69.4% of FPMs were healthy (sound or with noncavitated caries) in the baseline groups completely sealed, incompletely sealed and nonsealed FPMs, respectively. Incompletely sealed fissures were more susceptible to caries development than completely sealed fissures. It is important that incompletely sealed fissures are resealed as soon as possible.

Economic impact of disease prevention in a morbidity-based financing system: does prevention pay off for a statutory health insurance fund in Germany?

Preventable chronic diseases account for the greatest burden in the German health system and statutory health insurance (SHI) funds play a crucial role in implementing and financing prevention strategies. On the contrary, the morbidity-based scheme to distribute financial resources from the Central Reallocation Pool among the different sickness funds may counteract efforts of effective prevention from an economic perspective. We assessed financial impacts of prevention from a sickness funds perspective in a retrospective controlled study. Claims data of 6,247,275 persons were analyzed and outcomes between two propensity-matched groups (n = 852,048) of prevention users and non-users were compared in a 4-year follow-up. Using a difference-in-differences approach, we analyzed healthcare expenditures, the development of morbidity, financial transfers from the Central Reallocation Pool, and contribution margins. The group of prevention users develops less morbidity (incidences and disease aggravations) compared to the control group. Healthcare expenditures increase in both groups within 4 years, whereas the increase is lower for prevention users compared to non-users (€568.04 vs. €640.60, p < 0.0001). Taking morbidity-based financial transfers into account, the decrease in contribution margins is stronger for prevention users (- €188.44 vs. - €138.73, p < 0.0001). This study demonstrates an economic disincentive from a sickness funds' perspective. In the semi-competitive SHI market, sickness funds will be discouraged from effective prevention strategies if investments are not worth it financially. Their efforts and knowledge are, however, crucial for joint action to foster prevention over cure in the health system.

Treating High-Caries Risk Occlusal Surfaces in First Permanent Molars through Sealants and Supervised Toothbrushing: A 3-Year Cost-Effective Analysis

We conducted a 3-year cost-effectiveness analysis on the cavitated dentine carious lesion preventive capabilities of composite resin (CR) (reference group) and atraumatic restorative treatment (ART) high-viscosity glass-ionomer cement (HVGIC) sealants compared to supervised toothbrushing (STB) in high-risk first permanent molars. School children aged 6-7 years in 6 schools (2 per group) received CR and ART/HVGIC sealants or STB daily for 180 days each school year. Data were collected prospectively and cost estimates were made for sample data and a projection of 1,000 sealants/STB high-risk permanent molars. Although STB had the best outcome, its high implementation cost (95% of cost for supervisors visiting schools 180 days/school year) affected the results. ART/HVGIC was cost-effective compared to CR for the sample data (savings of USD 37 per cavitated dentine carious lesion prevented), while CR was cost-effective compared to ART/HVGIC for the projection (savings of USD 17 per cavitated dentine carious lesion prevented), and both were cost-saving compared to STB. Two STB scenarios were tested in sensitivity analyses with variations in caries incidence and number of supervision days; results showed STB had lower costs and higher savings per cavitated dentine carious lesion prevented than CR and ART/HVGIC. A major assumption is that both scenarios have the same high effectiveness rate experienced by STB under study conditions; however, they point to the value of further research on the benefits of adopting STB as a long-term venture in a general population of school children.

Casein phosphopeptide-amorphous calcium phosphate products in caries prevention

Data sourcesMedline, Embase, PreMedline and Cochrane Central Register of Controlled Trials.Study selectionClinical trials, investigating only clinical caries outcomes on participants of any age comparing the use of Tooth Mousse(®) or Tooth Mousse Plus(®) to a routine oral care regimen for the prevention of dental caries with or without comparison to additional preventive products. Studies that used other formulations of CCP-ACP were excluded. Trials using split-mouth design were also excluded. Only English language papers were considered.Data extraction and synthesisPapers were assessed independently by both authors using the Cochrane Collaboration tool for assessing risk of bias in randomised trials.1 Meta-analysis was not possible due to study heterogeneity.ResultsTwelve studies were available for the final review; three studies on caries prevention were assessed as having low risk of bias. The remaining nine studies, with high risk of bias, reported on treatment or regression of early carious lesions. Two RCTs reported no significant benefits in the use of Tooth Mousse(®) over brushing with a fluoride toothpaste, a third study demonstrated a statistically significant increase in enamel microhardness for the Tooth Mousse(®) group compared to control group but no difference to the group who had fluoride gel treatment. Overall the authors concluded that Tooth Mousse(®) performs no better than fluoride in the prevention of carious lesions.Seven of nine studies evaluated caries lesion severity in orthodontic patients, with four demonstrating statistically significant white spot regression. Two trials in non-orthodontic patients showed statistically significant remineralising potential of Tooth Mousse(®) over fluoride mouthrinse or the regular use of fluoride toothpaste in 14-30 days.ConclusionsThe authors found no evidence to support the use of Tooth Mousse(®) over brushing with a fluoride toothpaste for the prevention of early caries. ToothMousse(®) appeared to benefit regression of white spot lesions associated with orthodontic treatment but the evidence is limited. Effectiveness of Tooth Mousse(®) was not significantly increased by the addition of fluoride in Tooth Mousse Plus(®) and evidence is still lacking to support the use of one over another. High quality randomised clinical trials are needed before these products can be recommended for the prevention and treatment of early carious lesions in the general population.Source of fundingThe publication was funded by Colgate Palmolive, Australia.

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

BACKGROUND

Most of the detected increment in dental caries among children and adolescents is confined to occlusal surfaces of posterior permanent molars. Dental sealants and fluoride varnishes are much used preventive options for caries. Although the effectiveness of sealants and fluoride varnishes for controlling caries as compared with no intervention has been demonstrated in clinical trials and summarised in systematic reviews, the relative effectiveness of these two interventions remains unclear. This review is an update of one first published in 2006 and last updated in 2010.

OBJECTIVES

Primary objective • To evaluate the relative effectiveness of fissure sealants compared with fluoride varnishes, or fissure sealants together with fluoride varnishes compared with fluoride varnishes alone, for preventing dental caries in the occlusal surfaces of permanent teeth of children and adolescents. Secondary objectives • To evaluate whether effectiveness is influenced by sealant material type and length of follow-up.• To document and report on data concerning adverse events associated with sealants and fluoride varnishes.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (to 18 December 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 11), MEDLINE via Ovid (1946 to 18 December 2015) and EMBASE via Ovid (1980 to 18 December 2015). We also searched the US National Institutes of Health Trials Register (http://clinicaltrials.gov) and the World Health Organization (WHO) Clinical Trials Registry Platform for ongoing trials. We placed no restrictions on language or date of publication when searching electronic databases. We screened the reference lists of identified trials and review articles for additional relevant studies.

SELECTION CRITERIA

We included randomised controlled trials with at least 12 months of follow-up comparing fissure sealants, or fissure sealants together with fluoride varnishes, versus fluoride varnishes for preventing caries in the occlusal surfaces of permanent premolar or molar teeth, in participants younger than 20 years of age at the start of the study.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results, extracted data and assessed risk of bias of included studies. We attempted to contact study authors to obtain missing or unclear information.We grouped and analysed studies on the basis of sealant material type (resin-based sealant and glass ionomer-based sealant: glass ionomer and resin-modified glass ionomer) and different follow-up periods. We calculated the odds ratio (OR) for caries or no caries on occlusal surfaces of permanent molar teeth. For trials with a split-mouth design, we used the Becker-Balagtas odds ratio. For continuous outcomes and data, we used means and standard deviations to obtain mean differences. We presented all measures with 95% confidence intervals (CIs).We assessed the quality of the evidence using GRADE (Grades of Recommendation, Assessment, Development and Evaluation) methods.We conducted meta-analysis using the fixed-effect model, as data from only two studies were combined. We had planned to conduct meta-analyses using a random-effects model when more than three trials were included in the meta-analysis.

MAIN RESULTS

In this review, we included eight trials with 1746 participants (four of the trials were new since the 2010 update). Seven trials (1127 participants) contributed to the analyses, and children involved were five to 10 years of age at the start of the trial. Sealant versus fluoride varnish Resin-based fissure sealants compared with fluoride varnishes Four trials evaluated this comparison (three of them contributing to the analyses). Compared with fluoride varnish, resin-based sealants prevented more caries in first permanent molars at two-year follow-up (two studies in the meta-analysis with pooled odds ratio (OR) 0.69, 95% confidence interval (CI) 0.50 to 0.94; P value = 0.02; I(2) = 0%; 358 children evaluated). We assessed the body of evidence as low quality. The caries-preventive benefit for sealants was maintained at longer follow-up in one trial at high risk of bias: 26.6% of sealant teeth and 55.8% of fluoride-varnished teeth had developed caries when 75 children were evaluated at nine years of follow-up. Glass ionomer-based sealants compared with fluoride varnishes Three trials evaluated this comparison: one trial with chemically cured glass ionomer and two with resin-modified glass ionomer. Researchers reported similar caries increment between study groups regardless of which glass ionomer material was used in a trial. Study designs were clinically diverse, and meta-analysis could not be conducted. The body of evidence was assessed as of very low quality. Sealant together with fluoride varnish versus fluoride varnish alone One split-mouth trial analysing 92 children at two-year follow-up found a significant difference in favour of resin-based fissure sealant together with fluoride varnish compared with fluoride varnish only (OR 0.30, 95% CI 0.17 to 0.55). The body of evidence was assessed as low quality. Adverse events Three trials (two with resin-based sealant material and one with resin-modified glass ionomer) reported that no adverse events resulted from use of sealants or fluoride varnishes. The other five studies did not mention adverse events.

AUTHORS' CONCLUSIONS

Currently, scarce and clinically diverse data are available on the comparison of sealants and fluoride varnish applications; therefore it is not possible to draw clear conclusions about possible differences in effectiveness for preventing or controlling dental caries on occlusal surfaces of permanent molars. The conclusions of this updated review remain the same as those of the last update (in 2010). We found some low-quality evidence suggesting the superiority of resin-based fissure sealants over fluoride varnish applications for preventing occlusal caries in permanent molars, and other low-quality evidence for benefits of resin-based sealant and fluoride varnish over fluoride varnish alone. Regarding glass ionomer sealant versus fluoride varnish comparisons, we assessed the quality of the evidence as very low and could draw no conclusions.