British Society of Paediatric Dentistry: a policy document on fissure sealants in paediatric dentistry

Clinical interventions with various agents to prevent early childhood caries: A systematic review with network meta-analysis

BACKGROUND

Dental caries is one of the most prevalent chronic diseases among preschool children globally. Different preventive agents and combinations have been studied. However, the rank of the effectiveness of clinical interventions is equivocal.

AIM

To summarize and rank the effectiveness of clinical interventions using different agents for primary prevention of early childhood caries (ECC).

DESIGN

Two reviewers independently searched PubMed, Embase, and Cochrane Library to identify randomized controlled trials with at least 12-month follow-up. The network meta-analysis (NMA) on different agents was based on a random-effects model and frequentist approach. Standardized mean differences (SMD) with 95% CI of the caries increment were calculated in terms of either dmft or dmfs and used in the NMA. Caries incidences at the child level were compared using odds ratios (ORs) with 95% CI. The effectiveness of the agents was ranked using the surface under the cumulative ranking curve (SUCRA).

RESULTS

After screening 3807 publications and selection, the NMA finally included 33 trials. These trials used either a single or combination of agents such as fluorides, chlorhexidine, casein phosphopeptide-amorphous calcium phosphate, probiotics, xylitol, and triclosan. Compared with control, fluoride foam (FF; SMD -0.69, 95% CI: -1.06, -0.32) and fluoride salt (F salt; SMD -0.66, 95% CI: -1.20, -0.13) were effective in preventing caries increment. Probiotic milk plus low fluoride toothpaste (PMLFTP; OR 0.34, 95% CI: 0.15, 0.77), FF (OR 0.48, 95% CI: 0.37, 0.63), fluoride varnish (FV; OR 0.63, 95% CI: 0.48, 0.81), and fluoride varnish plus high fluoride toothpaste (FVHFTP; OR 0.73, 95% CI: 0.57, 0.93) were effectively preventing caries incidence. According to the SUCRA, FF ranked first in preventing caries increment, whereas PMLFTP ranked first in preventing caries incidence.

CONCLUSION

Fluoride foam, F salt, PMLFTP, FV, and FVHFTP all effectively reduce caries increment or caries incidence in preschool children, but the evidence indicates low degree of certainty. Considering the relatively small number of studies, confidence in the findings, and limitations in the study, clinical practitioners and readers should exercise caution when interpreting the NMA results.

Comparison of clinical effectiveness of conventional and self-etch sealant: a split mouth randomized controlled trial

Background: Self-etching has been shown to be beneficial compared to the other resin sealants especially in pediatric practice. The present in-vivo study was designed to clinically evaluate the sealing ability and retention of the self-etching sealant compared to the conventional resin sealant. The aim was to evaluate and compare the retention and marginal integrity of the self-etch and acid etch sealant materials at three, six and twelve-month follow up.

Methods: The study was designed as a double blinded, split mouth randomized controlled trial, . In total, 35 children (70 teeth) between 7 and 10 years of age formed part of the study. Group 1 received acid-etch sealant and Group 2 received self-etch sealants. The study participants and the investigator who performed the statistical analysis were blinded to the treatment allocation. All the samples were evaluated at 3, 6, and 12 months. The inter-group and intragroup comparison were carried out using the Chi-Square test and Friedman test with level of significance set at 5% and the P value less than 0.05.

Results: Complete retention of sealants was observed in 34.5% of conventional acid etch (group 1) and 22.9% of self-etch samples (group 2) whereas complete loss of sealants were seen in 11.4% of group 1 and 20% of the group 2 samples and intergroup comparison of retention failure was non-significant (p=0.135). In total, 85.7% of the group 1 and 82.9% of the group 2 samples exhibited good marginal integrity with no clinical changes in the enamel around the margins but this was not statistically significant (p=0.5).

Conclusions: Sealants with fewer procedural steps and those which provide adequate retention would be ideal for use in children. Thus, self-etch sealants have been found to be effective and efficient as a sealant in the present in-vivo study.

Clinical Trials Registry, India registration: CTRI/2019/03/018343 (29/03/2019).

Glass Ionomer Sealant versus Fluoride Varnish Application to Prevent Occlusal Caries in Primary Second Molars among Preschool Children: A Randomized Controlled Trial

Fissure sealant is a recommended preventive measure on permanent molars, but its efficacy on primary molars in preschool children is still in doubt. Sodium fluoride varnish (NaFV) enhances remineralization and is effective in preventing caries in smooth surfaces, but limited information is available regarding its use on occlusal surfaces of primary molars. The present study aimed to compare the efficacy of glass ionomer sealant (GIS) versus topical application of 5% NaFV in preventing and arresting occlusal caries in primary second molars among preschool children. One calibrated examiner examined children aged 3-4 years for visible plaque index (VPI), decayed-missing-filled primary surface (dmfs) index, and extent of carious lesions by the International Caries Detection and Assessment System (ICDAS). Subjects with 1 or more primary second molars that were sound or with incipient lesions (ICDAS 0-1), with distinct visual enamel changes (ICDAS 2), or with localized enamel breakdown (ICDAS 3) were recruited. The children were randomly assigned to either NaFV group - application of 5% NaFV at 3-monthly intervals or GIS group - 1 single placement of GIS. A parental questionnaire was used to collect information on the children's sociodemographic background and oral health-related habits. Two blinded examiners conducted clinical examinations after 6 and 12 months to evaluate the development of occlusal caries and the retention of GIS. Negative binomial regression using generalized estimating equations was employed to adjust for the clustering effect and evaluate the influence of selected variables on the development of occlusal caries into dentin at 12 months. A total of 323 children with 1,159 primary second molars received the respective preventive measures at baseline. At 12 months, 280 children with 989 molars were evaluated. Caries had developed or progressed into dentin in 7.8% and 8.0% of the molars in the NaFV and GIS groups, respectively, with no significant difference between the groups (p = 0.913). The overall retention rates of GIS were 24.6% and 13.5% at 6 and 12 months, respectively. Regression analyses showed only baseline caries experience, and an ICDAS code had a significant association with occlusal caries progression. Quarterly NaFV application and single GIS placement showed similar effectiveness in the prevention of occlusal caries development among preschool children.

The Use of Pit and Fissure Sealants-A Literature Review

This paper reviews the literature and discusses the latest updates on the use of pit and fissure sealants. It demonstrates the effectiveness of pit and fissure sealants in preventing caries and the management of early carious lesions. It compares the use of different sealant materials and their indications. It describes the application technique for sealants. It also reviews the cost-effectiveness of sealants as a preventive strategy. From this review and after the discussion of recently published studies on pit and fissure sealants, it is evident that sealants are effective in caries prevention and in preventing the progression of incipient lesions. It is therefore recommended that pit and fissure sealant be applied to high-caries-risk children for optimum cost-effectiveness. It is a highly sensitive technique that needs optimum isolation, cleaning of the tooth surface, etching, and the application of a thin bonding layer for maximum benefit. Recall and repair, when needed, are important to maximize the effectiveness of such sealant use.

Evidence not practised: the underutilisation of preventive fissure sealants

International and UK professional organisations, Cochrane systematic reviews, and international and UK guidance documents all support the application of preventive fissure sealants (PFSs) as an effective treatment for reducing caries. However, PFSs are well known to be underutilised in primary care. This paper collates data from PFS-relevant studies in Scotland, which has a large population of children at caries risk, to identify the beliefs and factors dentists perceive as influencing their decision not to provide this treatment. This information provides a platform to suggest how to increase the application of PFSs in this region (a standardised audit incorporating evidence-based behaviour change techniques, supplemental guidance on how to implement gold-standard recommendations in practice, training). This may also be relevant outside of Scotland, as well as to the implementation of other evidence-based behaviours in practice.

Protocol for "Seal or Varnish?" (SoV) trial: a randomised controlled trial to measure the relative cost and effectiveness of pit and fissure sealants and fluoride varnish in preventing dental decay

BACKGROUND

Dental caries remains a significant public health problem, prevalence being linked to social and economic deprivation. Occlusal surfaces of first permanent molars are the most susceptible site in the developing permanent dentition. Cochrane reviews have shown pit and fissure sealants (PFS) and fluoride varnish (FV) to be effective over no intervention in preventing caries. However, the comparative cost and effectiveness of these treatments is uncertain. The primary aim of the trial described in this protocol is to compare the clinical effectiveness of PFS and FV in preventing dental caries in first permanent molars in 6-7 year-olds. Secondary aims include: establishing the costs and the relative cost-effectiveness of PFS and FV delivered in a community/school setting; examining the impact of PFS and FV on children and their parents/carers in terms of quality of life/treatment acceptability measures; and examining the implementation of treatment in a community setting.

METHODS/DESIGN

The trial design comprises a randomised, assessor-blinded, two-arm, parallel group trial in 6-7 year old schoolchildren. Clinical procedures and assessments will be performed at 66 primary schools, in deprived areas in South Wales. Treatments will be delivered via a mobile dental clinic. In total, 920 children will be recruited (460 per trial arm). At baseline and annually for 36 months dental caries will be recorded using the International Caries Detection and Assessment System (ICDAS) by trained and calibrated dentists. PFS and FV will be applied by trained dental hygienists. The FV will be applied at baseline, 6, 12, 18, 24 and 30 months. The PFS will be applied at baseline and re-examined at 6, 12, 18, 24, and 30 months, and will be re-applied if the existing sealant has become detached/is insufficient. The economic analysis will estimate the costs of providing the PFS versus FV. The process evaluation will assess implementation and acceptability through acceptability scales, a schools questionnaire and interviews with children, parents, dentists, dental nurses and school staff. The primary outcome measure will be the proportion of children developing new caries on any one of up to four treated first permanent molars.

DISCUSSION

The objectives of this study have been identified by the National Institute for Health Research as one of importance to the National Health Service in the UK. The results of this trial will provide guidance on which of these technologies should be adopted for the prevention of dental decay in the most susceptible tooth-surface in the most at risk children.

TRIAL REGISTRATIONS

ISRCTN ref: ISRCTN17029222 EudraCT: 2010-023476-23 UKCRN ref: 9273.

Applying psychological theories to evidence-based clinical practice: identifying factors predictive of placing preventive fissure sealants

BACKGROUND

Psychological models are used to understand and predict behaviour in a wide range of settings, but have not been consistently applied to health professional behaviours, and the contribution of differing theories is not clear. This study explored the usefulness of a range of models to predict an evidence-based behaviour -- the placing of fissure sealants.

METHODS

Measures were collected by postal questionnaire from a random sample of general dental practitioners (GDPs) in Scotland. Outcomes were behavioural simulation (scenario decision-making), and behavioural intention. Predictor variables were from the Theory of Planned Behaviour (TPB), Social Cognitive Theory (SCT), Common Sense Self-regulation Model (CS-SRM), Operant Learning Theory (OLT), Implementation Intention (II), Stage Model, and knowledge (a non-theoretical construct). Multiple regression analysis was used to examine the predictive value of each theoretical model individually. Significant constructs from all theories were then entered into a 'cross theory' stepwise regression analysis to investigate their combined predictive value.

RESULTS

Behavioural simulation - theory level variance explained was: TPB 31%; SCT 29%; II 7%; OLT 30%. Neither CS-SRM nor stage explained significant variance. In the cross theory analysis, habit (OLT), timeline acute (CS-SRM), and outcome expectancy (SCT) entered the equation, together explaining 38% of the variance. Behavioural intention - theory level variance explained was: TPB 30%; SCT 24%; OLT 58%, CS-SRM 27%. GDPs in the action stage had significantly higher intention to place fissure sealants. In the cross theory analysis, habit (OLT) and attitude (TPB) entered the equation, together explaining 68% of the variance in intention.

SUMMARY

The study provides evidence that psychological models can be useful in understanding and predicting clinical behaviour. Taking a theory-based approach enables the creation of a replicable methodology for identifying factors that may predict clinical behaviour and so provide possible targets for knowledge translation interventions. Results suggest that more evidence-based behaviour may be achieved by influencing beliefs about the positive outcomes of placing fissure sealants and building a habit of placing them as part of patient management. However a number of conceptual and methodological challenges remain.

Assessment of the accuracy of visual examination, bite-wing radiographs and DIAGNOdent on the diagnosis of occlusal caries

AIM

This was to evaluate the accuracy of the different methods for diagnosing occlusal caries in vivo, and to compare their performance in primary and permanent teeth.

STUDY DESIGN

Permanent teeth (199) and primary molars (65) with macroscopically intact occlusal surface, with caries lesions without cavitation (white spot) or with a darkened sulcus were selected. The teeth were examined by the following methods: visual inspection, bite-wing radiographs and DIAGNOdent. The validation method employed for asserting the existence of carious lesion was cavity preparation.

RESULTS

When the total sample was taken into consideration, laser (DIAGNOdent) provided the highest accuracy (74.8%). Even when the total sample was stratified, the laser accuracy was still high for both primary (88.4%) and permanent molars (70.4%). Visual inspection also provided a high accuracy for primary teeth (83.9%). The chi-square test showed a statistically significant difference between permanent and primary teeth considering occlusal caries diagnosis (p=0.0001). The Kappa coefficient showed good inter-examiner reproducibility for all methods. McNemar test revealed that the degree of intra-examiner agreement for visual inspection was lower than for the other methods.

CONCLUSIONS

As visual inspection also showed a high degree of accuracy, the laser method should be used as a complementary method in doubtful cases. Diagnostic methods of occlusal caries, in general, are more efficient in deciduous than in permanent teeth.

The dental health and preventative habits of cardiac patients attending the Royal Hospital for Sick Children Glasgow

AIM

To assess the dental health and preventive practices of child patients with congenital heart disease treated at the Royal Hospital for Sick Children, Glasgow.

STUDY DESIGN

A retrospective study using an audit data collection sheet.

METHODS

Data collected for 370 paediatric cardiac patients between January 2002 and December 2003 was analysed to obtain an insight into these patients' tooth brushing methods, use of fluoride (F), dental attendance and past dental treatment. An oral examination assessed the patient's caries experience.

RESULTS

There were 195 subjects aged between 1 and 5 years, 105 were 6 - 11 years and 70 were 12 -16 years of whom 291 (78%) children were registered for dental care. Of these children 331 (90%) maintained that they brushed their teeth regularly with F- toothpaste. Experience of dental treatment revealed that 132 (36%) children had undergone previous dental treatment. Oral examination showed that out of 370 patients, 236 (64%) had no active caries. The dental health of the cardiac subjects was poor compared with that of Scottish primary school children (5 year-olds) and the 12 year-olds but compared favourably with the 14-year old group.

STATISTICS

The relationship between caries activity and frequency of toothbrushing was significant (p<0.01). The relationship between caries activity and attendance for dental care was not significant.

CONCLUSION

Children with cardiac problems should be identified in early infancy through liaison with medical colleagues and the family offered all the preventive advice and regular dental care necessary to prevent dental disease.

A randomized controlled trial of the effectiveness of a one-step conditioning agent in sealant placement: 6-month results

AIM

The objectives of this study were: to compare the retention of fissure sealants (sealants) placed on occlusal surfaces following the use of a self-etching priming agent and traditional acid etch; to compare the caries incidence of occlusal surfaces sealed using the two techniques; and to compare the ease of placement of sealant following the use of the two techniques, as assessed by subjects and operators.

DESIGN

The study took the form of a randomized controlled trial conducted in UK National Health Service community dental service and dental hospital clinics. Sixty subjects were recruited to this study by seven dental professionals who placed sealants on lower permanent molar pairs. The technique used for enamel preparation prior to sealant placement on the right and left side of the lower arch was randomized. On one side of the lower arch, Xeno III was used to prepare the occlusal enamel, and on the other, phosphoric acid etch together with Prime & Bond was used. Opaque Delton was used to seal all surfaces. Subjects were blinded to the techniques used. The subjects and operators recorded their impressions of the techniques used on individual questionnaires.

RESULTS

Forty-six (77%) of the 60 subjects were reviewed by the principal researcher after 6 months. The retention of the acid-etch group was significantly superior (P < 0.01), as was the caries preventive effect (P < 0.01). Subjects tended to report that placement of sealants was easier following enamel preparation with Xeno III (P = 0.085), and in the opinion of the operators, sealants were significantly easier to place when using Xeno III (P = 0.016).

CONCLUSIONS

In view of the findings of this investigation, best practice for the placement of sealants remains enamel preparation with acid etch and the use of an intermediate bonding layer.