The impact of recent changes in the epidemiology of dental caries on guidelines for the use of dental sealants

Microtensile Bond Strength of Bioactive Pit and Fissure Sealants Bonded to Primary and Permanent Teeth

Background: Sealing occlusal pits and fissures is an effective preventive measure against dental caries. Pit and fissure sealants (PFS) should be strongly bonded to the teeth to prevent partial or complete loss of the sealant, which may limit its preventive effect. Objective: The objective of the study was to compare the microtensile bond strength (μTBS) of bioactive resin-based sealants (Bio-RBS) and resin-based sealants (RBS), with and without the use of a bonding agent, to the enamel of primary and permanent teeth. Methods: One hundred and twenty caries-free primary molar specimens and 120 permanent molar specimens were divided to eight groups (30 specimens per group), both primary and permanent teeth were sealed with a Bio-RBS BioCoat^TM (Premier^®, Plymouth Meeting, PA, USA) or with a RBS Clinpro^TM (3M ESPE, Saint Paul, MN, USA), with or without the use of a bonding agent (Prime & Bond NT; Dentsply, Inc., Charlotte, NC, USA). Half the specimens were aged with 5000 thermal cycles, and all specimens were tested for the μTBS and failure mode. Results: The mean μTBS of aged Bio-RBS was higher in permanent teeth than primary teeth, and the aging process reduced the μTBS of RBS more than that of Bio-RBS. Moreover, the addition of a bonding agent improved the μTBS of aged RBS in permanent teeth. Conclusion: We concluded that Bio-RBS exhibit superior μTBS than RBS when applied to permanent teeth.

Caries experience between primary teeth at 3-5 years of age and future caries in the permanent first molars

Background/purpose

Past caries experience remains the most powerful predictor of future caries. This study was aimed at exploring the possible relationship between the caries statuses at 3–5 and 8–10 years of age and examining the predictive power of caries experience at 3–5 years of age for the caries pattern at 8–10 years of age.

Materials and methods

A total of 76 children (43 boys and 33 girls) were included in this study from 2012 to 2018. The first caries examination, performed in 2012, was completed when participants underwent dental rehabilitation under general anesthesia at 3–5 years of age. Tooth decay was recorded based on the International Caries Detection and Assessment System criteria. The caries examination was repeated in the clinic in 2018 when the participants were 8–10 years old. Associations between the permanent and primary teeth were analyzed using the Mann–Whitney U test. The receiver operating characteristic curve analysis was performed to determine the predictive accuracy of the primary dentition.

Results

A significant dmfs score of the primary second molar was found between groups of free dentin caries and dentin caries of the permanent first molars (p = 0.002). The calculated areas under the receiver operating characteristic curve for the dmfs score of the primary second molar was 0.74.

Conclusion

Caries in the primary second molars is a clinically useful predictor at 3–5 years of age for future dentin caries development on surfaces of the first permanent molars in the following 5 years.

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 above the age of six years and adolescents is confined to occlusal surfaces of posterior permanent molars. Dental sealants and fluoride varnishes are much used to prevent caries. As the effectiveness of both interventions in controlling caries as compared with no intervention has been demonstrated previously, this review aimed to evaluate their relative effectiveness. It updates a review published originally in 2006 and updated in 2010 and in 2016.

OBJECTIVES

Our primary objective was to evaluate the relative effectiveness of dental sealants (i.e. fissure sealant) compared with fluoride varnishes, or fissure sealants plus fluoride varnishes compared with fluoride varnishes alone, for preventing dental caries in the occlusal surfaces of permanent teeth of children and adolescents. Our secondary objectives were to evaluate whether effectiveness is influenced by sealant material type and length of follow-up, document and report on data concerning adverse events associated with sealants and fluoride varnishes, and report the cost effectiveness of dental sealants versus fluoride varnish in caries prevention.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 19 March 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2020, Issue 2), MEDLINE Ovid (1946 to 19 March 2020) and Embase Ovid (1980 to 19 March 2020). We searched the US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. There were no restrictions on the language or date of publication.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

At least two review authors independently screened search results, extracted data from included studies and assessed their risk of bias. 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 or glass ionomer-based sealant (glass ionomer and resin-modified glass ionomer sealant), and different follow-up periods. We calculated the odds ratio (OR) for risk of caries on occlusal surfaces of permanent molar teeth. For trials with a split-mouth design, we used the Becker-Balagtas OR. One cluster-randomised trial provided precise estimates in terms of risk ratio (RR), which we used. For continuous outcomes and data, we used means and standard deviations to obtain mean differences (MD). For meta-analysis, we used the random-effects model when we combined data from four or more studies. We presented all measures with 95% confidence intervals (CIs). We assessed the certainty of the evidence using GRADE criteria.

MAIN RESULTS

We included 11 trials with 3374 participants aged five to 10 years when trials started. Three trials are new since the 2016 update. Two trials did not contribute data to our analysis. Sealant versus fluoride varnish Resin-based fissure sealants versus fluoride varnishes Seven trials evaluated this comparison (five contributing data). We are uncertain if resin-based sealants may be better than fluoride varnish, or vice versa, for preventing caries in first permanent molars at two to three years' follow-up (OR 0.67, 95% CI 0.37 to 1.19; I² = 84%; 4 studies, 1683 children evaluated). One study measuring decayed, missing and filled permanent surfaces (DMFS) and decayed, missing and filled permanent teeth (DMFT) increment at two years suggested a small benefit for fissure sealant (DMFS MD -0.09, 95% CI -0.15 to -0.03; DMFT MD -0.08, 95% CI -0.14 to -0.02; 542 participants), though this may not be clinically significant. One small study, at high risk of bias, reported a benefit for sealant after four years in preventing caries (RR 0.42, 95% CI 0.21 to 0.84; 75 children) and at nine years (RR 0.48, 95% CI 0.29 to 0.79; 75 children). We assessed each of these results as having very low certainty. Glass ionomer-based sealants versus fluoride varnishes Three trials evaluated this comparison: one trial with chemically cured glass ionomer and two with resin-modified glass ionomer. Studies were clinically diverse, so we did not conduct a meta-analysis. In general, the studies found no benefit of one intervention over another at one, two and three years, although one study, which also included oral health education, suggested a benefit from sealants over varnish for children at high risk of caries. We assessed this evidence as very low certainty. Sealant plus fluoride varnish versus fluoride varnish alone One split-mouth trial analysing 92 children at two-year follow-up found in favour of resin-based fissure sealant plus fluoride varnish over fluoride varnish only (OR 0.30, 95% CI 0.17 to 0.55), which represented a clinically meaningful effect of a 77% reduction in caries after two years; however, we assessed this evidence as very low certainty. Adverse events Five trials (1801 participants) (four using resin-based sealant material and one using resin-modified glass ionomer) reported that no adverse events resulted from use of sealants or fluoride varnishes over one to nine years. The other studies did not mention adverse events.

AUTHORS' CONCLUSIONS

Applying fluoride varnish or resin-based fissure sealants to first permanent molars helps prevent occlusal caries, but it has not been possible in this review to reach reliable conclusions about which one is better to apply. The available studies do not suggest either intervention is superior, but we assessed this evidence as having very low certainty. We found very low-certainty evidence that placing resin-based sealant as well as applying fluoride varnish works better than applying fluoride varnish alone. Fourteen studies are currently ongoing and their findings may allow us to draw firmer conclusions about whether sealants and varnish work equally well or whether one is better than the other.

Recall intervals for oral health in primary care patients

BACKGROUND

There is ongoing debate about the frequency with which patients should attend for a dental check-up and the effects on oral health of the interval between check-ups. Recommendations regarding optimal recall intervals vary between countries and dental healthcare systems, but 6-month dental check-ups have traditionally been advocated by general dental practitioners in many high-income countries. This review updates a version first published in 2005, and updated in 2007 and 2013.

OBJECTIVES

To determine the optimal recall interval of dental check-up for oral health in a primary care setting.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 17 January 2020), the Cochrane Central Register of Controlled Trials (CENTRAL; in the Cochrane Library, 2019, Issue 12), MEDLINE Ovid (1946 to 17 January 2020), and Embase Ovid (1980 to 17 January 2020). We also searched the US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. We placed no restrictions on the language or date of publication when searching.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) assessing the effects of different dental recall intervals in a primary care setting.

DATA COLLECTION AND ANALYSIS

Two review authors screened search results against inclusion criteria, extracted data and assessed risk of bias, independently and in duplicate. We contacted study authors for clarification or further information where necessary and feasible. We expressed the estimate of effect as mean difference (MD) with 95% confidence intervals (CIs) for continuous outcomes and risk ratios (RR) with 95% CIs for dichotomous outcomes. We assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included two studies with data from 1736 participants. One study was conducted in a public dental service clinic in Norway and involved participants under 20 years of age who were regular attenders at dental appointments. It compared 12-month with 24-month recall intervals and measured outcomes at two years. The other study was conducted in UK general dental practices and involved adults who were regular attenders, which was defined as having attended the dentist at least once in the previous two years. It compared the effects of 6-month, 24-month and risk-based recall intervals, and measured outcomes at four years. The main outcomes we considered were dental caries, gingival bleeding and oral-health-related quality of life. Neither study measured other potential adverse effects. 24-month versus 12-month recall at 2 years' follow-up Due to the very low certainty of evidence from one trial, it is unclear if there is an important difference in caries experience between assignment to a 24-month or a 12-month recall. For 3- to 5-year-olds with primary teeth, the mean difference (MD) in dmfs (decayed, missing, and filled tooth surfaces) increment was 0.90 (95% CI -0.16 to 1.96; 58 participants). For 16- to 20-year-olds with permanent teeth, the MD in DMFS increment was 0.86 (95% CI -0.03 to 1.75; 127 participants). The trial did not assess other clinical outcomes of relevance to this review. Risk-based recall versus 6-month recall at 4 years' follow-up We found high-certainty evidence from one trial of adults that there is little to no difference between risk-based and 6-month recall intervals for the outcomes: number of tooth surfaces with any caries (ICDAS 1 to 6; MD 0.15, 95% CI -0.77 to 1.08; 1478 participants); proportion of sites with gingival bleeding (MD 0.78%, 95% CI -1.17% to 2.73%; 1472 participants); oral-health-related quality of life (MD in OHIP-14 scores -0.35, 95% CI -1.02 to 0.32; 1551 participants). There is probably little to no difference in the prevalence of moderate to extensive caries (ICDAS 3 to 6) between the groups (RR 1.04, 95% CI 0.99 to 1.09; 1478 participants; moderate-certainty evidence). 24-month recall versus 6-month recall at 4 years' follow-up We found moderate-certainty evidence from one trial of adults that there is probably little to no difference between 24-month and 6-month recall intervals for the outcomes: number of tooth surfaces with any caries (MD -0.60, 95% CI -2.54 to 1.34; 271 participants); percentage of sites with gingival bleeding (MD -0.91%, 95% CI -5.02% to 3.20%; 271 participants). There may be little to no difference between the groups in the prevalence of moderate to extensive caries (RR 1.05, 95% CI 0.92 to 1.20; 271 participants; low-certainty evidence). We found high-certainty evidence that there is little to no difference in oral-health-related quality of life between the groups (MD in OHIP-14 scores -0.24, 95% CI -1.55 to 1.07; 305 participants). Risk-based recall versus 24-month recall at 4 years' follow-up We found moderate-certainty evidence from one trial of adults that there is probably little to no difference between risk-based and 24-month recall intervals for the outcomes: prevalence of moderate to extensive caries (RR 1.06, 95% CI 0.95 to 1.19; 279 participants); number of tooth surfaces with any caries (MD 1.40, 95% CI -0.69 to 3.49; 279 participants). We found high-certainty evidence that there is no important difference between the groups in the percentage of sites with gingival bleeding (MD -0.07%, 95% CI -4.10% to 3.96%; 279 participants); or in oral-health-related quality of life (MD in OHIP-14 scores -0.37, 95% CI -1.69 to 0.95; 298 participants).

AUTHORS' CONCLUSIONS

For adults attending dental check-ups in primary care settings, there is little to no difference between risk-based and 6-month recall intervals in the number of tooth surfaces with any caries, gingival bleeding and oral-health-related quality of life over a 4-year period (high-certainty evidence). There is probably little to no difference between the recall strategies in the prevalence of moderate to extensive caries (moderate-certainty evidence). When comparing 24-month with either 6-month or risk-based recall intervals for adults, there is moderate- to high-certainty evidence that there is little to no difference in the number of tooth surfaces with any caries, gingival bleeding and oral-health-related quality of life over a 4-year period. The available evidence on recall intervals between dental check-ups for children and adolescents is uncertain. The two trials we included in the review did not assess adverse effects of different recall strategies.

Effectiveness of Fluoridation Depending on Periodicity in 6–10-year-old Children

Background

The cost-effectiveness of this study was achieved in the group that was treated every three months with periodic intervals, which had a reduction of caries with 62%. The relative effectiveness of our study is the application of fluoride treatment every 3 months compared with treatments done every 4 and 6 months, respectively.

Objective

To evaluate the reduction of caries disease depending on the time period of fluoride gel application. The sample was chosen randomly.

Main hypothesis

The frequency of fluoride gel application every 3 months has positive impacts on reducing dental caries.

Basic design

This is a cross-sectional study with a controlled sample for a period of 24 months. Durashield fluoride fluid (5% sodium fluoride) was used for the treatment of permanent dentition of the 6–10-year-old children.

Clinical setting

This study proves that fuoride application every 3 months significantly reduces caries morbidity.

Participants

Our study included 400 children, who were divided into 4 groups, 100 children in each group.

Intervention

The first group did not undergo any treatment and it is called the control group. The second group was under fluoride treatment every 4 months. The third group was treated with fluoride every 3 months, and the fourth group was treated every 6 months.

Results

The data collected from the control group showed that there is an increase in 24% of the caries incidence. In the group treated with fluoride every 4 months, caries incidence decreased to 30%. The group treated every 3 months with periodic intervals had a reduction of caries with 62%, while the group treated every 6 months had a reduction of 40%. Based on the analysis of variance (ANOVA) test, the fluoridation application every 3 months is significant for p = 0.000.

Conclusion

The best results were achieved in the treatment with fluoride in a 3-month periodic interval.

How to cite this article

Canga M, Malagnino VA et al. Effectiveness of Fluoridation Depending on Periodicity in 6–10-year-old Children. Int J Clin Pediatr Dent 2019;12(4):280–282.

Pit and fissure sealants for preventing dental decay in permanent teeth

BACKGROUND

Dental sealants were introduced in the 1960s to help prevent dental caries, mainly in the pits and fissures of occlusal tooth surfaces. Sealants act to prevent bacteria growth that can lead to dental decay. Evidence suggests that fissure sealants are effective in preventing caries in children and adolescents compared to no sealants. Effectiveness may, however, be related to caries incidence level of the population. This is an update of a review published in 2004, 2008 and 2013.

OBJECTIVES

To compare the effects of different types of fissure sealants in preventing caries in occlusal surfaces of permanent teeth in children and adolescents.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched: Cochrane Oral Health's Trials Register (to 3 August 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2016, Issue 7), MEDLINE Ovid (1946 to 3 August 2016), and Embase Ovid (1980 to 3 August 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials to 3 August 2016. No restrictions were placed on language or date of publication.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing sealants with no sealant or a different type of sealant material for preventing caries of occlusal surfaces of premolar or molar teeth in children and adolescents aged up to 20 years. Studies required at least 12 months follow-up. We excluded studies that compared compomers to resins/composites.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results, extracted data and assessed risk of bias of included studies. We presented outcomes for caries or no caries on occlusal surfaces of permanent molar teeth as odds ratio (OR) or risk ratio (RR). We used mean difference (MD) for mean caries increment. All measures were presented with 95% confidence intervals (CI). We conducted meta-analyses using a random-effects model for comparisons where there were more than three trials; otherwise we used the fixed-effect model. We used GRADE methods to assess evidence quality.

MAIN RESULTS

We included 38 trials that involved a total of 7924 children; seven trials were new for this update (1693 participants). Fifteen trials evaluated the effects of resin-based sealant versus no sealant (3620 participants in 14 studies plus 575 tooth pairs in one study); three trials with evaluated glass ionomer sealant versus no sealant (905 participants); and 24 trials evaluated one type of sealant versus another (4146 participants). Children were aged from 5 to 16 years. Trials rarely reported background exposure to fluoride of trial participants or baseline caries prevalence. Resin-based sealant versus no sealant: second-, third- and fourth-generation resin-based sealants prevented caries in first permanent molars in children aged 5 to 10 years (at 24 months follow-up: OR 0.12, 95% CI 0.08 to 0.19, 7 trials (5 published in the 1970s; 2 in the 2010s), 1548 children randomised, 1322 children evaluated; moderate-quality evidence). If we were to assume that 16% of the control tooth surfaces were decayed during 24 months of follow-up (160 carious teeth per 1000), then applying a resin-based sealant would reduce the proportion of carious surfaces to 5.2% (95% CI 3.13% to 7.37%). Similarly, assuming that 40% of control tooth surfaces were decayed (400 carious teeth per 1000), then applying a resin-based sealant would reduce the proportion of carious surfaces to 6.25% (95% CI 3.84% to 9.63%). If 70% of control tooth surfaces were decayed, there would be 19% decayed surfaces in the sealant group (95% CI 12.3% to 27.2%). This caries-preventive effect was maintained at longer follow-up but evidence quality and quantity was reduced (e.g. at 48 to 54 months of follow-up: OR 0.21, 95% CI 0.16 to 0.28, 4 trials, 482 children evaluated; RR 0.24, 95% CI 0.12 to 0.45, 203 children evaluated). Although studies were generally well conducted, we assessed blinding of outcome assessment for caries at high risk of bias for all trials (blinding of outcome assessment is not possible in sealant studies because outcome assessors can see and identify sealant). Glass ionomer sealant versus no sealant: was evaluated by three studies. Results at 24 months were inconclusive (very low-quality evidence). One sealant versus another sealant: the relative effectiveness of different types of sealants is unknown (very low-quality evidence). We included 24 trials that directly compared two different sealant materials. Comparisons varied in terms of types of sealant assessed, outcome measures chosen and duration of follow-up. Adverse events: only four trials assessed adverse events. No adverse events were reported.

AUTHORS' CONCLUSIONS

Resin-based sealants applied on occlusal surfaces of permanent molars are effective for preventing caries in children and adolescents. Our review found moderate-quality evidence that resin-based sealants reduced caries by between 11% and 51% compared to no sealant, when measured at 24 months. Similar benefit was seen at timepoints up to 48 months; after longer follow-up, the quantity and quality of evidence was reduced. There was insufficient evidence to judge the effectiveness of glass ionomer sealant or the relative effectiveness of different types of sealants. Information on adverse effects was limited but none occurred where this was reported. Further research with long follow-up is needed.

Retention and caries-preventive effect of glass ionomer and resin-based sealants: An 18-month-randomized clinical trial

The objective of this study was to compare the retention and caries-preventive effect of glass ionomer (Fuji Triage) and resin-based (Clinpro) sealants among 6-9-year-old children. This split-mouth, randomized clinical trial covered 35 children/140 fully erupted permanent first molars. Evaluation was conducted by two independent examiners after 6, 12, and 18 months and the data were compared in relation to the children's caries risk and age groups. The Kaplan-Meier survival method and chi-square test were used for analysis. There were no statistically significant differences in the survival of partial and fully retained sealants or in the survival of caries-free pits and fissures between glass-ionomer and resin-based sealants. In terms of retention, both sealants performed better in the younger age group at the end of the study, and showed better caries prevention in moderate caries risk children. After 18 months, both sealants had comparable retention and caries-preventive effects in 6-9-year old children.

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.

Clinical comparison of Fuji VII and a resin sealant in children at high and low risk of caries

The purpose was to compare the retention and caries preventive effect of Fuji VII and a resin-based sealant in children at high risk (HR) and low risk (LR) of caries. Fifty-seven schoolchildren (150 teeth) with completely erupted bilateral permanent first molars were included. The study was a split-mouth, randomized trial. Sealant retention and caries were evaluated after 6 months, 1 year and 2 years. After 2 years, there was no statistically significant difference in the incidence of caries between Fuji VII and Concise in the HR and LR groups. With Concise, LR children were less likely to have dental caries than HR. With Fuji VII, there was no difference in caries incidence between LR and HR. Retention of Concise was superior to that of Fuji VII. Our results suggest that Fuji VII and Concise sealants had similar caries preventive effects in children at high and low risk of caries.

Recall intervals for oral health in primary care patients

BACKGROUND

The frequency with which patients should attend for a dental check-up and the potential effects on oral health of altering recall intervals between check-ups have been the subject of ongoing international debate in recent decades. Although recommendations regarding optimal recall intervals vary between countries and dental healthcare systems, six-monthly dental check-ups have traditionally been advocated by general dental practitioners in many developed countries.This is an update of a Cochrane review first published in 2005, and previously updated in 2007.

OBJECTIVES

To determine the beneficial and harmful effects of different fixed recall intervals (for example six months versus 12 months) for the following different types of dental check-up: a) clinical examination only; b) clinical examination plus scale and polish; c) clinical examination plus preventive advice; d) clinical examination plus preventive advice plus scale and polish.To determine the relative beneficial and harmful effects between any of these different types of dental check-up at the same fixed recall interval.To compare the beneficial and harmful effects of recall intervals based on clinicians' assessment of patients' disease risk with fixed recall intervals.To compare the beneficial and harmful effects of no recall interval/patient driven attendance (which may be symptomatic) with fixed recall intervals.

SEARCH METHODS

The following electronic databases were searched: the Cochrane Oral Health Group's Trials Register (to 27 September 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 9), MEDLINE via OVID (1946 to 27 September 2013) and EMBASE via OVID (1980 to 27 September 2013). We searched the US National Institutes of Health Trials Register (http://clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (http://www.who.int/ictrp/en/) for ongoing trials. Reference lists from relevant articles were scanned and the authors of some papers were contacted to identify further trials and obtain additional information. We did not apply any restrictions regarding language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) assessing the effects of different dental recall intervals.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the search results against the inclusion criteria of the review, extracted data and carried out risk of bias assessment. We contacted study authors for clarification or further information where necessary and feasible. If we had found more than one study with similar comparisons reporting the same outcomes, we would have combined the studies in a meta-analysis using a random-effects model if there were at least four studies, or a fixed-effect model if there were less than four studies. We expressed the estimate of effect as mean difference with 95% confidence intervals (CIs) for continuous outcomes. We would have used risk ratios with 95% CI for any dichotomous outcomes.

MAIN RESULTS

We included one study that analysed 185 participants. The study compared the effects of a clinical examination every 12 months with a clinical examination every 24 months on the outcomes of caries (decayed, missing, filled surfaces (dmfs/DMFS) increment) and economic cost outcomes (total time used per person). As the study was at high risk of bias, had a small sample size and only included low-risk participants, we rated the quality of the body of evidence for these outcomes as very low.For three to five-year olds with primary teeth, the mean difference (MD) in dmfs increment was -0.90 (95% CI -1.96 to 0.16) in favour of 12-month recall. For 16 to 20-year olds with permanent teeth, the MD in DMFS increment was -0.86 (95% CI -1.75 to 0.03) also in favour of 12-month recall. There is insufficient evidence to determine whether 12 or 24-month recall with clinical examination results in better caries outcomes.For three to five-year olds with primary teeth, the MD in time used by each participant was 10 minutes (95% CI -6.7 to 26.7) in favour of 24-month recall. For 16 to 20-year olds with permanent teeth, the MD was 23.7 minutes (95% CI 4.12 to 43.28) also in favour of 24-month recall. This single study at high risk of bias represents insufficient evidence to determine whether 12 or 24-month recall with clinical examination results in better time/cost outcomes.

AUTHORS' CONCLUSIONS

There is a very low quality body of evidence from one RCT which is insufficient to draw any conclusions regarding the potential beneficial and harmful effects of altering the recall interval between dental check-ups. There is no evidence to support or refute the practice of encouraging patients to attend for dental check-ups at six-monthly intervals. It is important that high quality RCTs are conducted for the outcomes listed in this review in order to address the objectives of this review.

The success rates of a glass ionomer cement and a resin-based fissure sealant placed by fifth-year undergraduate dental students

AIM

To evaluate retention and caries prevention of a glass-ionomer cement (GIC) and a resin-based fissure sealant placed by fifth-year undergraduate dental students.

METHODS

The study was conducted according to a split-mouth, randomised clinical trial. Children with at least one pair of caries-free permanent first molars with deep pits and fissures were included in the study. The children were selected from a population that had a high risk for dental caries. Sealant materials were applied by fifth-year undergraduate dental students on 346 fissures of the first permanent molars in 173 children. The ages of the children ranged from 7-15 years (mean 9.4). Two researchers at the clinics supervised all of the procedures. Intra-examiner reproducibility and inter-examiner reproducibility were 0.90 and 0.86, respectively, for the clinical assessment of sealant retention and caries evaluation.

RESULTS

GIC sealants were completely lost in 31.9% and resin-based sealants in 16.6% (p<0.05). The total retention rates of GIC sealants and resin-based sealants were 13.8% and 20.8%, respectively. After 24 months, the caries increment was 3.4% for GIC sealants and 4.8% for resin-based sealants (p>0.05).

CONCLUSIONS

The retention of GIC sealants was markedly inferior to the retention of resin-based sealants; however, GIC when used as a pit and fissure sealant was slightly more effective in preventing occlusal caries.

Sealants for preventing dental decay in the permanent teeth

BACKGROUND

Dental sealants were introduced in the 1960s to help prevent dental caries in the pits and fissures of mainly the occlusal tooth surfaces. Sealants act to prevent the growth of bacteria that can lead to dental decay. There is evidence to suggest that fissure sealants are effective in preventing caries in children and adolescents when compared to no sealants. Their effectiveness may be related to the caries prevalence in the population.

OBJECTIVES

To compare the effects of different types of fissure sealants in preventing caries in permanent teeth in children and adolescents.

SEARCH METHODS

We searched the Cochrane Oral Health Group's Trials Register (to 1 November 2012); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 7); MEDLINE via OVID (1946 to 1 November 2012); EMBASE via OVID (1980 to 1 November 2012); SCISEARCH, CAplus, INSPEC, NTIS and PASCAL via STN Easy (to 1 September 2012); and DARE, NHS EED and HTA (via the CAIRS web interface to 29 March 2012 and thereafter via Metaxis interface to September 2012). There were no language or publication restrictions. We also searched for ongoing trials via ClinicalTrials.gov (to 23 July 2012).

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials of at least 12 months duration comparing sealants for preventing caries of occlusal or approximal surfaces of premolar or molar teeth with no sealant or different type of sealant in children and adolescents under 20 years of age.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results, extracted data and assessed trial quality. 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, the Becker-Balagtas odds ratio was used. For mean caries increment we used the mean difference. All measures are presented with 95% confidence intervals (CI). The quality of the evidence was assessed using GRADE methods. We conducted the meta-analyses using a random-effects model for those comparisons where there were more than three trials in the same comparison, otherwise the fixed-effect model was used.

MAIN RESULTS

Thirty-four trials are included in the review. Twelve trials evaluated the effects of sealant compared with no sealant (2575 participants) (one of those 12 trials stated only number of tooth pairs); 21 trials evaluated one type of sealant compared with another (3202 participants); and one trial evaluated two different types of sealant and no sealant (752 participants). Children were aged from 5 to 16 years. Trials rarely reported the background exposure to fluoride of the trial participants or the baseline caries prevalence.- Resin-based sealant compared with no sealant: Compared to control without sealant, second or third or fourth generation resin-based sealants prevented caries in first permanent molars in children aged 5 to 10 years (at 2 years of follow-up odds ratio (OR) 0.12, 95% confidence interval (CI) 0.07 to 0.19, six trials (five published in the 1970s and one in 2012), at low risk of bias, 1259 children randomised, 1066 children evaluated, moderate quality evidence). If we were to assume that 40% of the control tooth surfaces were decayed during 2 years of follow-up (400 carious teeth per 1000), then applying a resin-based sealant will reduce the proportion of the carious surfaces to 6.25% (95% CI 3.84% to 9.63%); similarly if we were to assume that 70% of the control tooth surfaces were decayed  (700 carious teeth per 1000), then applying a resin-based sealant will reduce the proportion of the carious surfaces to 18.92% (95% CI 12.28% to 27.18%). This caries preventive effect was maintained at longer follow-up but both the quality and quantity of the evidence was reduced (e.g. at 48 to 54 months of follow-up OR 0.21, 95% CI 0.16 to 0.28, four trials (two studies at low risk of bias and two studies at high risk of bias), 482 children evaluated; risk ratio (RR) 0.24, 95% CI 0.12 to 0.45, one study at unclear risk of bias, 203 children evaluated).- Glass ionomer sealant compared with no sealant: There is insufficient evidence to make any conclusions about whether glass ionomer sealants, prevent caries compared to no sealant at 24-month follow-up (mean difference in DFS -0.18, 95% CI -0.39 to 0.03, one trial at unclear risk of bias, 452 children randomised, 404 children evaluated, very low quality evidence).- Sealant compared with another sealant: The relative effectiveness of different types of sealants remained inconclusive in this review. Twenty-one trials directly compared two different sealant materials. Several different comparisons were made according to type of sealant, outcome measure and duration of follow-up. There was great variation with regard to comparisons, outcomes, time of outcomes reported and background fluoride exposure if this was reported.Fifteen trials compared glass ionomer with resin sealants and there is insufficient evidence to make any conclusions about the superiority of either of the two materials. Although there were 15 trials the event rate was very low in many of these which restricted their contribution to the results.Three trials compared resin-modified glass ionomer with resin sealant and reported inconsistent results.Two small low quality trials compared polyacid-modified resin sealants with resin sealants and found no difference in caries after 2 years.- Adverse effects: Only two trials mentioned adverse effects and stated that no adverse effects were reported by participants.

AUTHORS' CONCLUSIONS

The application of sealants is a recommended procedure to prevent or control caries. Sealing the occlusal surfaces of permanent molars in children and adolescents reduces caries up to 48 months when compared to no sealant, after longer follow-up the quantity and quality of the evidence is reduced. The review revealed that sealants are effective in high risk children but information on the magnitude of the benefit of sealing in other conditions is scarce. The relative effectiveness of different types of sealants has yet to be established.

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.

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.

The use of dental sealants in adults: a long-neglected preventive measure

The consensus among the general public appears to be that dental sealants are intended to be used primarily with children whose teeth are in the early developmental stage, yet little attention is given to the preventive long-term aspects when applying them to adult permanent dentition. This article explores the rationale and substantiates the use of dental sealants among the adult population in reducing occlusal pit-and-fissure caries while accentuating a beneficial oral health lifestyle.

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.

Recall intervals for oral health in primary care patients

BACKGROUND

The frequency with which patients should attend for a dental check-up and the potential effects on oral health of altering recall intervals between check-ups have been the subject of ongoing international debate for almost 3 decades. Although recommendations regarding optimal recall intervals vary between countries and dental healthcare systems, 6-monthly dental check-ups have traditionally been advocated by general dental practitioners in many developed countries.

OBJECTIVES

To determine the beneficial and harmful effects of different fixed recall intervals (for example 6 months versus 12 months) for the following different types of dental check-up: a) clinical examination only; b) clinical examination plus scale and polish; c) clinical examination plus preventive advice; d) clinical examination plus preventive advice plus scale and polish. To determine the relative beneficial and harmful effects between any of these different types of dental check-up at the same fixed recall interval. To compare the beneficial and harmful effects of recall intervals based on clinicians' assessment of patients' disease risk with fixed recall intervals. To compare the beneficial and harmful effects of no recall interval/patient driven attendance (which may be symptomatic) with fixed recall intervals.

SEARCH STRATEGY

We searched the Cochrane Oral Health Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Reference lists from relevant articles were scanned and the authors of some papers were contacted to identify further trials and obtain additional information. Date of most recent searches: 5th March 2007.

SELECTION CRITERIA

Trials were selected if they met the following criteria: design - random allocation of participants; participants - all children and adults receiving dental check-ups in primary care settings, irrespective of their level of risk for oral disease; interventions - recall intervals for the following different types of dental check-ups: a) clinical examination only; b) clinical examination plus scale and polish; c) clinical examination plus preventive advice; d) clinical examination plus scale and polish plus preventive advice; e) no recall interval/patient driven attendance (which may be symptomatic); f) clinician risk-based recall intervals; outcomes - clinical status outcomes for dental caries (including, but not limited to, mean dmft/DMFT, dmfs/DMFS scores, caries increment, filled teeth (including replacement restorations), early carious lesions arrested or reversed); periodontal disease (including, but not limited to, plaque, calculus, gingivitis, periodontitis, change in probing depth, attachment level); oral mucosa (presence or absence of mucosal lesions, potentially malignant lesions, cancerous lesions, size and stage of cancerous lesions at diagnosis). In addition the following outcomes were considered where reported: patient-centred outcomes, economic cost outcomes, other outcomes such as improvements in oral health knowledge and attitudes, harms, changes in dietary habits and any other oral health-related behavioural change.

DATA COLLECTION AND ANALYSIS

Information regarding methods, participants, interventions, outcome measures and results were independently extracted, in duplicate, by two review authors. Authors were contacted, where deemed necessary and where possible, for further details regarding study design and for data clarification. A quality assessment of the included trial was carried out. The Cochrane Collaboration's statistical guidelines were followed.

MAIN RESULTS

Only one study (with 188 participants) was included in this review and was assessed as having a high risk of bias. This study provided limited data for dental caries outcomes (dmfs/DMFS increment) and economic cost outcomes (reported time taken to provide examinations and treatment).

AUTHORS' CONCLUSIONS

There is insufficient evidence from randomised controlled trials (RCTs) to draw any conclusions regarding the potential beneficial and harmful effects of altering the recall interval between dental check-ups. There is insufficient evidence to support or refute the practice of encouraging patients to attend for dental check-ups at 6-monthly intervals. It is important that high quality RCTs are conducted for the outcomes listed in this review in order to address the objectives of this review.

Dental caries

Dental caries, otherwise known as tooth decay, is one of the most prevalent chronic diseases of people worldwide; individuals are susceptible to this disease throughout their lifetime. Dental caries forms through a complex interaction over time between acid-producing bacteria and fermentable carbohydrate, and many host factors including teeth and saliva. The disease develops in both the crowns and roots of teeth, and it can arise in early childhood as an aggressive tooth decay that affects the primary teeth of infants and toddlers. Risk for caries includes physical, biological, environmental, behavioural, and lifestyle-related factors such as high numbers of cariogenic bacteria, inadequate salivary flow, insufficient fluoride exposure, poor oral hygiene, inappropriate methods of feeding infants, and poverty. The approach to primary prevention should be based on common risk factors. Secondary prevention and treatment should focus on management of the caries process over time for individual patients, with a minimally invasive, tissue-preserving approach.

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 is confined to pit and fissure surfaces of first molars. Application of pit and fissure sealants and topical fluorides are widely used procedures in the prevention of decay, and their effectiveness in caries prevention has been proved by systematic reviews.

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

Electronic searching was performed on the following databases: the Cochrane Oral Health Group's Trials Register (last update November 2005), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2005, Issue 4), MEDLINE (from 1966 to December 2005), EMBASE (from 1974 to November 2004), SIGLE (from 1976 to December 2004), SCISEARCH, CAplus, INSPEC, JICST-EPLUS, NTIS, PASCAL (last update December 2004), DARE, NHS EED and HTA (last update November 2005). Reference lists from articles that fulfilled the inclusion criteria in this review and from review articles based on the search of MEDLINE were searched for additional relevant articles. Conference abstracts published as books or journals and handsearched by the Cochrane Oral Health Group were also included.

SELECTION CRITERIA

The inclusion criteria for study selection were: random or quasi-random allocation study design; sealants versus fluoride varnish or sealants and fluoride varnish combination versus fluoride varnish alone; included studies included caries documentation on occlusal surfaces of permanent molars and the subjects were under 20 years of age. Both parallel and split-mouth study designs were accepted. The primary outcome of interest was the increment in the numbers of carious occlusal surfaces of premolars and molars. A study was excluded if sealants and fluoride varnish were not compared with each other.

DATA COLLECTION AND ANALYSIS

Two review authors carried out the baseline searches, selecting the papers on the basis of the title, keywords and abstract and making decisions about the eligibility and data extractions. The same review authors assessed the methodological quality of all included studies: for example, the allocation concealment, blinding, and completeness of follow up. Authors of the studies were contacted for additional information. Risk ratios (RR) as effect estimates were calculated for the differences in whether surfaces were carious or not in the treatment groups, along with the appropriate standard errors and 95% confidence intervals (CI). 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. Three of the four studies compared the effectiveness of sealants with fluoride varnish application, and one study compared the effectiveness of sealants and fluoride varnish combination with fluoride varnish alone. Results of two studies 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 (RR 0.74, 95% CI 0.58 to 0.95) and at 9 years follow up (RR 0.48, 95% CI 0.29 to 0.79). One of these studies was classed as at low risk of bias, one of moderate to high risk. One small study at moderate to high risk of bias failed to find a statistically significant difference between sealants and fluoride varnishes. One study of low risk of bias found a statistically significant difference in favour of the sealants and fluoride varnish combination compared with merely fluoride varnish at 24 months follow up with RR 0.36 (95% CI 0.21 to 0.61). The age of children in the included studies was 5 to 9 years. Allocation concealment was classified adequate in two of these four studies.

AUTHORS' CONCLUSIONS

There was some evidence of the superiority of pit and fissure sealants over fluoride varnish application in the prevention of occlusal decays. However, it remained unclear to what extent there is difference between the effectiveness of pit and fissure sealants and fluoride varnishes. Therefore, more high quality research is needed. No recommendations for the clinical practice could be given and the benefit of pit and fissure sealants and fluoride varnishes should be considered locally and individually.

Assessing cost-effectiveness of sealant placement in children

OBJECTIVE

The lack of cost-effectiveness information regarding sealant placement strategies is thought to have influenced reimbursement policies and subsequent sealant utilization in dental practice. This study compared three strategies for managing the occlusal surfaces of first permanent molars: seal all (SA), risk-based (RBS), and seal none (SN).

METHODS

A decision tree was developed for various possible outcomes following each of the above strategies. Due to the complexity of the decision tree, a Markov model was used to allow for the construction of a chain of events representing the natural history of sealant retention, caries formation, and their associated health states. The outcome measures were the incremental cost per month gained in a cavity-free state over a ten-year period.

RESULTS

Our theoretical model showed that RBS strategy improved clinical outcomes, in the form of cavity-free months, and saved money over SN. The strategy of sealing both high and low risk teeth (SA) further improved outcomes but at an additional cost compared to RBS. However, the cost was small, .08 dollars for each additional cavity-free month gained per tooth. Further, minor changes in the baseline assumptions resulted in the SA strategy being the dominant strategy.

CONCLUSION

This study provides evidence that sealing children's first permanent molars can improve outcomes and save money by delaying or avoiding invasive treatment and the destructive cycle of caries. In a time of limited funds for dental services, these results can assist payers in establishing more rational sealant reimbursement policies.

Recall intervals for oral health in primary care patients

BACKGROUND

The frequency with which patients should attend for a dental check-up and the potential effects on oral health of altering recall intervals between check-ups have been the subject of ongoing international debate for almost 3 decades. Although recommendations regarding optimal recall intervals vary between countries and dental healthcare systems, 6-monthly dental check-ups have traditionally been advocated by general dental practitioners in many developed countries.

OBJECTIVES

To determine the beneficial and harmful effects of different fixed recall intervals (for example 6 months versus 12 months) for the following different types of dental check-up: a) clinical examination only; b) clinical examination plus scale and polish; c) clinical examination plus preventive advice; d) clinical examination plus preventive advice plus scale and polish. To determine the relative beneficial and harmful effects between any of these different types of dental check-up at the same fixed recall interval. To compare the beneficial and harmful effects of recall intervals based on clinicians' assessment of patients' disease risk with fixed recall intervals. To compare the beneficial and harmful effects of no recall interval/patient driven attendance (which may be symptomatic) with fixed recall intervals.

SEARCH STRATEGY

We searched the Cochrane Oral Health Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Reference lists from relevant articles were scanned and the authors of some papers were contacted to identify further trials and obtain additional information. Date of most recent searches: 9th April 2003.

SELECTION CRITERIA

Trials were selected if they met the following criteria: design- random allocation of participants; participants - all children and adults receiving dental check-ups in primary care settings, irrespective of their level of risk for oral disease; interventions -recall intervals for the following different types of dental check-ups: a) clinical examination only; b) clinical examination plus scale and polish; c) clinical examination plus preventive advice; d) clinical examination plus scale and polish plus preventive advice; e) no recall interval/patient driven attendance (which may be symptomatic); f) clinician risk-based recall intervals; outcomes - clinical status outcomes for dental caries (including, but not limited to, mean dmft/DMFT, dmfs/DMFS scores, caries increment, filled teeth (including replacement restorations), early carious lesions arrested or reversed); periodontal disease (including, but not limited to, plaque, calculus, gingivitis, periodontitis, change in probing depth, attachment level); oral mucosa (presence or absence of mucosal lesions, potentially malignant lesions, cancerous lesions, size and stage of cancerous lesions at diagnosis). In addition the following outcomes were considered where reported: patient-centred outcomes, economic cost outcomes, other outcomes such as improvements in oral health knowledge and attitudes, harms, changes in dietary habits and any other oral health-related behavioural change.

DATA COLLECTION AND ANALYSIS

Information regarding methods, participants, interventions, outcome measures and results were independently extracted, in duplicate, by two authors. Authors were contacted, where deemed necessary and where possible, for further details regarding study design and for data clarification. A quality assessment of the included trial was carried out. The Cochrane Oral Health Group's statistical guidelines were followed.

MAIN RESULTS

Only one study (with 188 participants) was included in this review and was assessed as having a high risk of bias. This study provided limited data for dental caries outcomes (dmfs/DMFS increment) and economic cost outcomes (reported time taken to provide examinations and treatment).

AUTHORS' CONCLUSIONS

There is insufficient evidence from randomised controlled trials (RCTs) to draw any conclusions regarding the potential beneficial and harmful effects of altering the recall interval between dental check-ups. There is insufficient evidence to support or refute the practice of encouraging patients to attend for dental check-ups at 6-monthly intervals. It is important that high quality RCTs are conducted for the outcomes listed in this review in order to address the objectives of this review.

Dental sealant longevity in a cohort of young U.S. naval personnel

BACKGROUND

The U.S. Navy emphasizes caries prevention and encourages the placement of dental sealants on the caries-susceptible teeth of patients at risk of developing caries. The authors analyzed dental records to assess the longevity of dental sealants placed in naval personnel.

METHODS

A cluster sample of dental records from 1,123 personnel who entered naval service in 1997 was drawn from eight Navy dental treatment facilities. The authors determined the number of sealants provided, the number of sealants that failed over the observation period (1997-2001), the dates of sealant failure and the longevity of sealants placed during and after recruit training.

RESULTS

A total of 319 personnel received sealants during their first two years of service. The authors evaluated 1,467 sealed teeth. They followed the sealants for an average of 35 months. They noted 179 sealant failures in 102 subjects; 69 previously sealed teeth required sealant replacement, and 110 sealed teeth required restoration of the occlusal surface. Among those sealants that failed, the mean length of time from placement to failure was 26 months. Sealant failure rates were significantly higher among subjects at moderate risk or high risk of developing caries than among subjects at low risk.

CONCLUSIONS

After an average of 35 months, 87.8 percent of the sealants placed in this population were retained and functional. Subjects who were at moderate or high risk of developing caries demonstrated significantly higher sealant failure rates than those at low risk of developing caries.

CLINICAL IMPLICATIONS

Dental sealants can be retained successfully in adults. They should be considered a viable treatment alternative for adult patients who are susceptible to caries; however, patients at elevated risk of developing caries may require more frequent re-evaluation and maintenance to achieve maximum benefit.

Identifying children with dental care needs: evaluation of a targeted school-based dental screening program

OBJECTIVES

It has been suggested that changes in the distribution of dental caries mean that targeting high-risk groups can maximize the cost effectiveness of dental health programs. This study aimed to assess the effectiveness of a targeted school-based dental screening program in terms of the proportion of children with dental care needs it identified.

METHODS

The target population was all children in junior and senior kindergarten and grades 2, 4, 6, and 8 who attended schools in four Ontario communities. The study was conducted in a random sample of 38 schools stratified according to caries risk. Universal screening was implemented in these schools. The parents of all children identified as having dental care needs were sent a short questionnaire to document the sociodemographic and family characteristics of these children. Children with needs were divided into two groups: those who would and who would not have been identified had the targeted program been implemented. The characteristics of the two groups were compared.

RESULTS

Overall, 21.0 percent of the target population were identified as needing dental care, with 7.4 percent needing urgent care. The targeted program would have identified 43.5 percent of those with dental care needs and 58.0 percent of those with urgent needs. There were substantial differences across the four communities in the proportions identified by the targeted program. Identification rates were lowest when the difference in prevalence of need between the high- and low-risk groups was small and where the low-risk group was large in relation to the high-risk group. The targeted program was more effective at identifying children from disadvantaged backgrounds. Of those with needs who lived in households receiving government income support, 59.0 percent of those with needs and 80.1 percent of those with urgent needs would be identified.

CONCLUSIONS

The targeted program was most effective at identifying children with dental care needs from disadvantaged backgrounds. However, any improvements in cost effectiveness achieved by targeting must be balanced against inequities in access to public health care resources.

Practitioner's guide to fluoride

The current health care trend is to provide evidence-based recommendations and treatment. Many literature reviews have shown fluoride's effectiveness against caries. The current use of fluoride in the prevention of dental caries is based on community, professional, and individual strategies. Personalized fluoride regimens should include a risk analysis and a review of the patient's current fluoride exposure. The future of fluoride may be found in its slow release and retention in the oral cavity through various modalities. Because of the many uncertainties still associated with fluoride, further research is needed.

Reviews of evidence on interventions to prevent dental caries, oral and pharyngeal cancers, and sports-related craniofacial injuries

This report presents the results of systematic reviews of effectiveness, applicability, other positive and negative effects, economic evaluations, and barriers to use of selected population-based interventions intended to prevent or control dental caries, oral and pharyngeal cancers, and sports-related craniofacial injuries. The related systematic reviews are linked by a common conceptual approach. These reviews form the basis of recommendations by the Task Force on Community Preventive Services (the Task Force) about the use of these selected interventions. The Task Force recommendations are presented in this supplement.

Targeting dental sealants in school-based programs: evaluation of an approach

Several guidelines have been published in the United States to promote the appropriate use of sealants in both individual care and public health programs. Targeting sealants to children and teeth at high risk for dental caries has been accepted as a desirable strategy in school-based programs. However, there is little evidence to show that programs are complying with these guidelines. This report examined the extent to which sealants were targeted to high-risk children at 11 different school-based programs in New York State. Data on 3357 children ages seven to nine were analyzed. The percent of children receiving sealants ranged from 41% to 88%. While in two sites (St. Lawrence & Onondaga) fewer than 52% of the children received sealants; more than 73% received sealants in the remaining nine sites (P < 0.05). The results suggest that there was a wide variation in the implementation of the guidelines for sealant use. Some reasons for not adhering to the guidelines were: difficulty in assuring parents and local dentists that some children were not at risk for caries; lack of confidence in the risk-assessment method; uncertainty regarding what constitutes deep pits and fissures; fear of misclassifying children and requests by school administrators, parents and local dentists that all children should benefit from preventive measures.

Treatment outcomes and costs of dental sealants among children enrolled in Medicaid

OBJECTIVES

This retrospective cohort analysis of children enrolled in the North Carolina Medicaid program compared the likelihood of restorative treatments and associated cumulative Medicaid expenditures for teeth with or without dental sealants.

METHODS

We assessed the dental experience of the cohort of 15 438 children from 1985 to 1992 on the basis of enrollment and claims files. We conducted regression analyses for outcomes (caries-related services involving the occlusal surface [CRSOs] of permanent first molars) and cumulative expenditures, controlling for characteristics of the child, the treating dentist, and the child's county of residence.

RESULTS

Overall, 23% of children received at least 1 sealant and 33% at least 1 CRSO. Sealants were effective in preventing CRSOs, although the degree of effectiveness was highest for children with the greater levels of CRSOs before sealant placement. Estimated cumulative Medicaid expenditures indicated expenditure savings from sealants within 2 years of application for children with 2 or more prior CRSOs.

CONCLUSIONS

Sealant placement was associated with expenditure savings to Medicaid for certain high-risk children, so Medicaid and, more broadly, society will benefit by providing for sealant placement in these children.

Community socioeconomic status and children's dental health

BACKGROUND

Although a substantial decline in dental caries has occurred among U.S. children, not everyone has benefited equally. The first-ever surgeon general's report on oral health in America indicates that the burden of oral diseases is found in poor Americans. This study investigates the relationship between community socioeconomic status, or SES, and dental health of children.

METHODS

An oral health survey of 17,256 children, representing 93 percent of children residing in 62 Tennessee communities, was conducted in public elementary schools during the 1996-1997 school year. Portable dental equipment was used for examinations, and data from each examination were entered directly into a laptop computer. The authors performed analyses of covariance to examine the relationship between community SES (low/medium/high) and dental health, controlling for community fluoridation.

RESULTS

Community SES was significantly related to caries experience in the primary teeth, the proportion of untreated caries in the primary and permanent teeth, dental treatment needs, dental sealants and incisor trauma. Overall, dental health was significantly worse for low-SES communities than for medium- and high-SES communities.

CONCLUSION

The authors conclude that all specific dental indexes used to measure children's dental health in this study, with the exceptions of caries experience in the permanent teeth and sealant presence, were inversely related to the communities' SES. The percentage of children with dental sealants was directly related to the community's SES.

PRACTICE IMPLICATIONS

Further improvements in oral health will necessitate that community-based preventive programs and access to quality dental care be made available to children who are identified as being at highest risk of experiencing oral disease.

Trends in preventive care: caries risk assessment and indications for sealants

BACKGROUND

In the 21st century, risk assessment models will continue to be developed. By understanding patients' susceptibility to disease, better treatment and preventive regimens can be offered. As the causative agent of dental caries is bacterial, the interaction between the susceptible host, the causative agent and the environment determine whether caries occurs--regardless of the patient's age.

CLINICAL IMPLICATIONS

This article reviews risk assessment for dental caries and the implication for developing preventive strategies. It also describes the indications and uses of sealants in the prevention of dental caries.

A comparison of sealant placement techniques and 12-month retention rates

OBJECTIVE

This study compared time required and 12-month retention for two methods of sealant placement: traditional acid-etch technique and air-abrasion technique without acid etch.

METHODS

Sealants were placed on the permanent first molars of 84 children in grades 1-4 who were randomly assigned to treatment groups. All sealants were placed in a school setting by the same clinician. Chair time required for sealant placement was recorded, and retention rates were determined for each technique 12 months after placement.

RESULTS

Mean chair time for placement of sealants on four first molars using the air-abrasion technique was significantly less than for the acid-etch technique (7:36 minutes vs 10:56 minutes). Fifty-eight children were available at 12-month follow-up; an examiner not involved in sealant placement and masked as to the technique used determined retention. Rates of complete retention for occlusal surfaces were not significantly different for the two techniques, although the rate for acid etch was higher than that for air abrasion (95% vs 87%). The complete retention rates for the acid-etch technique were significantly higher than air abrasion for buccal and distolingual surfaces. These rates were 65 percent and 58 percent, respectively, for acid etch and 6 percent and 28 percent, respectively, for air abrasion.

CONCLUSION

Although more research is needed to improve air-abrasion applications, it does not appear that air abrasion without acid etching offers a significant advantage over traditional sealant placement methods and, in fact, appears to be inferior to the acid-etch technique for use in public health settings.

"Risk periods" associated with the development of dental fluorosis in maxillary permanent central incisors: a meta-analysis

This systematic review of the dental literature (1966-98) concerns risk periods associated with dental fluorosis in the maxillary permanent central incisors. A literature search was organized through the MedLine and the ISI databases. In addition, one unpublished paper (in manuscript) was obtained, as well as one paper published before 1966. However, out of 143 catches, only 10 studies were included in this review. The main reason for exclusions was that the data presented did not meet the criteria given for the present meta-analysis. Among the included papers, 7 pertained to subjects whose exposure to fluoride started at different ages during the enamel formation (Group 1), and 3 were based on subjects who had been exposed from birth and then experienced an abrupt reduction in daily fluoride exposure at different ages during the amelogenesis period (Group 2). The meta-analysis for Group 1 found the odds ratio (OR) for dental fluorosis in children exposed to fluoride early in life (before 2 years of age) to be 7.24 (95% CI; 4.71-11.13) as compared to children exposed later in life (after 2 years of age). The meta-analysis for the studies in Group 2 found the overall OR to be 1.88 (95% CI; 1.35-2.61) for children who had a reduction in fluoride intake after 2 years of age, as compared to individuals who experienced reduction earlier (during the first 2 years). The studies from both groups were pooled and the duration of exposure to fluoride during the first 4 years of life was the independent variable. The meta-analysis now revealed an overall OR of 5.83 (95% CI; 2.83-11.94) for long periods of fluoride exposure (>2 out of the first 4 years) versus shorter periods of exposure (<2 out of the first 4 years of life) during the enamel formation in the maxillary central incisors. Based on the findings of the meta-analysis, no specific period of enamel formation is singled out as being the most critical for the development of dental fluorosis. The duration of fluoride exposure during the amelogenesis, rather than specific risk periods, would seem to explain the development of dental fluorosis in the maxillary permanent central incisor.

The impact of recent changes in the epidemiology of dental caries on guidelines for the use of dental sealants: clinical perspectives

When used properly, sealants result in improved dental health. However, their use on all occlusal tooth surfaces for preventive reasons will result in wasted dental care resources. To optimize the preventive effects of sealants, a delivery model should be initiated that uses specially trained dental hygienists or dental assistants who visit schools to explain oral health-related issues, conduct visual inspections of clinical oral health status, identify patients at risk for dental caries, and generate a central database for program operation. When a high-risk patient is identified, auxiliary personnel could place sealants and recall the patient for a new visual inspection six months later. If caries is suspected at that time, the patient could be sent to a dentist for additional treatment. To offset the negative effects caused by overutilization of sealants, their usage should be divided into two categories. First, a preventive option should be available, and the fee for use of sealants in this option should be lower compared to the fees used today. By using specially trained auxiliary personnel to place such sealants, the fee could be kept reasonably low. Second, a sealant treatments option that targets treatments of incipient lesions also should be available. The fee for such a treatment should be close to that of the traditional occlusal restoration, and the application should be by a dentist. By using such a fee structure based on market forces, one would expect that sealant usage would increase among patients suffering from early carious lesions, while the usage of preventive sealants would remain the same or decline. This utilization pattern for dental sealants would contribute to improved efficiency of sealant usage in the treatment of dental caries, particularly at a time when caries frequency is declining. The improved efficiency could release dental care resources that should be used to target risk groups with improved education in dental health. By using such a strategy, the long-term effect would be not only the placement of fewer restorations, but an improvement in dental health among adolescents and adults.