Arrest of non-cavitated dentinal occlusal caries by sealing pits and fissures: a 36-month, randomised controlled clinical trial

The Assessment of Resin-Based Composite Sealants' Effectiveness in Arresting Non-Cavitated Dentin Carious Lesions (ICDAS 3)-A 12 Month Follow-Up Preliminary Study

Background and Objectives: The therapeutic management of carious lesions remains a significant focus for researchers, given their persistently high prevalence despite being largely preventable. This study aimed to compare the effectiveness of a composite resin-based sealant material in halting extended non-cavitated dentin carious lesions when used therapeutically versus preventively on caries-free teeth over a period of twelve months. Materials and Methods: out of the 236 children examined, 45 were excluded from the study due to non-compliance with the inclusion criteria. Thus, the study included 191 children aged 10-12 years, and 764 molars in total. Results: among these molars, 171 were caries-free (ICDAS II code 0), forming the Control group, while 180 molars were classified with an ICDAS II score of 3, forming the Study group. All molars were sealed and evaluated at 6- and 12-month follow-up intervals. Both intervals revealed statistically significant differences (p < 0.05) in sealant retention and carious lesion development between sound (ICDAS code 0) and decayed (ICDAS code 3) teeth. Conclusions: the findings did not support the effectiveness of sealants in halting non-cavitated dentin carious lesions classified as ICDAS II with code 3 compared to their preventive application in sound teeth classified as ICDAS II with code 0.

The revolutionary evolution in carious lesion management

Contemporary paradigms of dental caries management focus on the biological approaches to treating the disease and its principal symptom, the carious lesion. This narrative review traces the evolution of carious lesion management from the operative and invasive approaches of G. V. Black's era to the current period of minimally invasive biological approaches. The paper explains the rationale for adopting biological approaches to dental caries management and lists the five core principles of this management approach. The paper also details the aims, features, and the most recent evidence base for the different biological carious lesion management approaches. Based on current practice guidelines, collated clinical pathways for lesion management are also presented in the paper to aid clinicians in their decision-making. It is hoped that the biological rationale and evidence summarized in this paper will bolster the shift to modern biological carious lesion management approaches among dental practitioners.

Dental Caries and Its Management

Objectives

In recent years, the management of dental caries has evolved significantly. Caries prevention, early detection, and a diagnosis based on risk indicators and risk factor assessments are the most current practical approaches. Furthermore, as proposed in minimally invasive dentistry, the new management approaches preserve healthy tissue and maintain pulp vitality. This article overviews the latest minimally invasive dental caries management and treatment options. The information will assist the reader in the early detection, diagnosis, and treatment of dental caries.

Materials and Methods

The PubMed (MEDLINE) search engine was used to gather the most relevant information on dental caries. The search was restricted to five years (May 30, 2018-May 29, 2022), and only English-language studies were accessed. A Boolean search of the PubMed data set was implemented to combine a range of keywords. The following filters were applied: abstract, free full text, full text, clinical trial, randomised control trial, systematic review, meta-analysis, and review. More studies were also obtained by manual searches from Google Scholar and textbooks on dental caries.

Results

By using this process, 683 articles and studies were obtained. The most relevant published studies were chosen and used in the current review. The selected articles are included in the references list. However, the search extended to cover the last five years as our understanding and management of dental caries have changed significantly.

Conclusions

Early detection and diagnosis of caries based on risk indicators and risk factor assessments are effective. Furthermore, minimally invasive restorative techniques are beneficial in managing dental caries and preserving healthy tissue and should be used whenever possible. This new information, knowledge, and materials should encourage professionals to implement this method. Having a strategy and system based on patient-centred care is critical, and our dental responsibilities must prioritise patient-centred care.

A concise review of dental sealants in caries management

This concise review provides an update of the use of dental sealants. Dental sealants protect a tooth from caries development by providing a physical barrier to microorganism colonisation and creating a favorable environment for patients to clean. Some sealants release fluoride ions to promote remineralization. Dental sealants can be applied on pits and fissures of primary and permanent teeth to prevent and arrest early enamel caries. They are effective in caries prevention. The preventive fraction of resin sealant is up to 61% after 5 years. Dental sealants can be classified as resin, glass ionomer and hybrid (compomer or giomer) according to the material. Recent studies from 2012 to 2022 showed resin sealant has a high retention rate of up to 80% after 2 years, whereas glass ionomer sealants is 44%. Chemical etching with 37% phosphoric acid is the standard of care, whereas laser or air-abrasion cannot does not increase the sealant retention rate. Moist control is critical and studies found the use of rubber dam and cotton rolls had similar success for sealant retention. The longevity of dental sealant is also associated with clinical operative factors, including approaches of moisture control, enamel pretreatment, selection of dental adhesive, and time of acid etching.

The Assessment of Sealants' Effectiveness in Arresting Non-Cavitated Caries Lesion-A 24-Month Follow-Up

Dental sealants are excellent means to prevent pits and fissure caries. Nowadays, the application of sealants is extended to therapeutic use in arresting non-cavitated carious lesions. This relatively new concept still lacks evidence to support its routine use. The aim of this study was to evaluate the effectiveness of a resin-based sealant applied on first permanent molars with carious lesions (ICDAS 1−3), in comparison with its effectiveness when applied on sound surfaces (ICDAS 0). Included in the study were 114 children aged between six and eight years old, with a high caries risk (according to the CAMBRA system), with all four permanent molars erupted and with deep pits and fissures. A total number of 407 molars were sealed and assessed. A total of 49 were excluded (they had caries, which according to the ICDAS II classification were classified with code 4−6 or had older sealants or fillings). Out of these 407 molars, 213 were sound (code 0) and 194 had caries lesions as follows: 56 teeth classified as code 1, 79 teeth classified as code 2, and 59 teeth classified as code 3 according to the ICDAS II classification. The retention of the sealant and carious lesions were assessed clinically at 6, 12, 18, and 24 months. Regarding sealant retention, a statistically significant difference (p < 0.05) among the two types of sealed teeth, sound (ICDAS 0) and decayed (ICDAS 3), showed at 18- and 24-month follow-up intervals. Regarding caries lesions, a statistically significant difference (p < 0.05) showed between sound (ICDAS 0) and decayed (ICDAS 3) molars at 24-month follow-up. Our study results supported the resin-based sealant effectiveness in arresting incipient carious lesions, which according to the ICDAS II classification have received codes 1 and 2 but did not support sealant effectiveness in arresting caries lesions classified according to the same classification with code 3.

Retention and caries-preventive effect of four different sealant materials: A 2-year prospective split-mouth study

AIM

The aim of this observational split-mouth study was to compare the retention and caries protective effect of four different sealant materials in children aged 6-13 years during a 2-year follow-up period.

DESIGN

Eighty children were included in this study, which was conducted in Blato (Korčula island), Croatia. Each participant received at least two different sealant materials on caries-free permanent molars in two different quadrants. Sealant materials (M1 - glass-ionomer cement; M2, M4 - resin-based filled sealants; M3 - resin-based unfilled sealant) were delivered in a random order.

RESULTS

The results of this study showed that M2 (30 teeth, 46.2%) and M4 (27 teeth, 46.6%) showed statistically significantly higher number of teeth with total retention after 2-year follow-up period, in comparison with M1 (10 teeth, 19.2%) or M3 (12 teeth, 20.7%) (p < .001). There was no statistically significant difference in caries occurrence between different groups in which the sealant material was totally retained.

CONCLUSIONS

According to the results of this study, filled resin-based sealant materials showed better retention during the 2-year follow-up period while both resin-based and glass-ionomer sealants demonstrated protection against dental caries if totally retained on the occlusal surface.

Flexural Strength, Elastic Modulus and Remineralizing Abilities of Bioactive Resin-Based Dental Sealants

Objective: To assess the remineralizing abilities and compare the flexural strength and elastic modulus of different bioactive pit and fissure sealants. Materials and Methods: Human enamel samples were randomly and blindly sealed with one of the following bioactive materials: BioCoat (Bc), ACTIVA KIDS (Av) and BeautiSealant (Bu). Seal-it (Si) was used as a non-bioactive sealant beside a control blank (B) group with no sealant. The sealed samples were subjected to a pH-cycling model (7 days of demineralization–remineralization cycles). The enamel surface hardness change (SHC), scanning electron microscopy-energy dispersive X-ray spectroscopy (SEM-EDX) and polarized light microscopy were used to assess the remineralizing abilities of the studied sealants. Flexural strength and elastic modulus were also assessed following the ISO 4049 protocols. One-way analysis of variance (ANOVA) was used to analyze the results. Results: Bc sealant showed the highest FS and EM (p < 0.05). The contact with Bc and Bu sealants showed significantly lower %SHL (p < 0.05) in comparison to the other. These findings were supported by the results of SEM-EDX and polarized imaging by showing higher percentages of calcium and phosphate ions with the former sealants and thinner demineralized enamel bands. Conclusion: In this study, Bc showed the highest flexural strength. Bc and Bu sealants outperformed the other studied sealants in terms of their remineralization abilities.

Minimally Invasive Therapies for the Management of Dental Caries—A Literature Review

In recent years, due to a better understanding of the caries pathology and advances in dental materials, the utilization of non-invasive and minimally invasive techniques that delay/obviate the need for traditional restorations has started gaining momentum. This literature review focuses on some of these approaches, including fluoride varnish, silver diamine fluoride, resin sealants, resin infiltration, chemomechanical caries removal and atraumatic restorative treatment, in the context of their chemistries, indications for use, clinical efficacy, factors determining efficacy and limitations. Additionally, we discuss strategies currently being explored to enhance the antimicrobial properties of these treatment modalities to expand the scope of their application.

The efficacy of dental sealant used with bonding agent on occlusal caries (ICDAS 2-4): A 24-month randomized clinical trial

BACKGROUND

Bonding before sealant application enhances retention on saliva-contaminated sound teeth; however, there are few studies of bonding's efficacy on sealant retention on occlusal caries.

AIM

To evaluate a bonding agent's efficacy on sealant retention on occlusal caries and caries transition.

DESIGN

One hundred twenty pairs of first permanent molars with occlusal caries (ICDAS 2-4) from 98 children aged 7.3-9.9 years were included. One molar was randomly selected to use bonding (Adper™ Single Bond 2, 3M ESPE) applied before sealant application (Helioseal^® clear, Ivoclar Vivadent). Bonding was not used on the contralateral tooth. Retention was determined using Simonsen's criteria; caries transition was evaluated using ICDAS scores, DIAGNOdent values, and bitewings at baseline, 6, 12, and 24 months. Data were analyzed with McNemar's and Fisher's exact tests.

RESULTS

Bonding agent use significantly increased sealant retention rates (P < .001). Bonded (B) sealants had a higher retention rate (83.3%) than non-bonded (NB) sealants (53.7%). The difference in the caries-transition rate was not significant between the groups (P > .05). Three teeth (1.4%; NB:B = 2:1) were restored due to radiographic dentin-caries progression.

CONCLUSIONS

Using a bonding agent before applying sealant on permanent molar occlusal caries (ICDAS 2-4) significantly enhanced sealant retention. Caries progression was rarely detected at the 24-month follow-up.

Interventions for treating cavitated or dentine carious lesions

BACKGROUND

Traditionally, cavitated carious lesions and those extending into dentine have been treated by 'complete' removal of carious tissue, i.e. non-selective removal and conventional restoration (CR). Alternative strategies for managing cavitated or dentine carious lesions remove less or none of the carious tissue and include selective carious tissue removal (or selective excavation (SE)), stepwise carious tissue removal (SW), sealing carious lesions using sealant materials, sealing using preformed metal crowns (Hall Technique, HT), and non-restorative cavity control (NRCC).

OBJECTIVES

To determine the comparative effectiveness of interventions (CR, SE, SW, sealing of carious lesions using sealant materials or preformed metal crowns (HT), or NRCC) to treat carious lesions conventionally considered to require restorations (cavitated or micro-cavitated lesions, or occlusal lesions that are clinically non-cavitated but clinically/radiographically extend into dentine) in primary or permanent teeth with vital (sensitive) pulps.

SEARCH METHODS

An information specialist searched four bibliographic databases to 21 July 2020 and used additional search methods to identify published, unpublished and ongoing studies.  SELECTION CRITERIA: We included randomised clinical trials comparing different levels of carious tissue removal, as listed above, against each other, placebo, or no treatment. Participants had permanent or primary teeth (or both), and vital pulps (i.e. no irreversible pulpitis/pulp necrosis), and carious lesions conventionally considered to need a restoration (i.e. cavitated lesions, or non- or micro-cavitated lesions radiographically extending into dentine). The primary outcome was failure, a composite measure of pulp exposure, endodontic therapy, tooth extraction, and restorative complications (including resealing of sealed lesions).

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently screened search results, extracted data, and assessed the risk of bias in the studies and the overall certainty of the evidence using GRADE criteria. We measured treatment effects through analysing dichotomous outcomes (presence/absence of complications) and expressing them as odds ratios (OR) with 95% confidence intervals (CI). For failure in the subgroup of deep lesions, we used network meta-analysis to assess and rank the relative effectiveness of different interventions.

MAIN RESULTS

We included 27 studies with 3350 participants and 4195 teeth/lesions, which were conducted in 11 countries and published between 1977 and 2020. Twenty-four studies used a parallel-group design and three were split-mouth. Two studies included adults only, 20 included children/adolescents only and five included both. Ten studies evaluated permanent teeth, 16 evaluated primary teeth and one evaluated both. Three studies treated non-cavitated lesions; 12 treated cavitated, deep lesions, and 12 treated cavitated but not deep lesions or lesions of varying depth.  Seventeen studies compared conventional treatment (CR) with a less invasive treatment: SE (8), SW (4), two HT (2), sealing with sealant materials (4) and NRCC (1). Other comparisons were: SE versus HT (2); SE versus SW (4); SE versus sealing  with sealant materials (2); sealant materials versus no sealing (2).  Follow-up times varied from no follow-up (pulp exposure during treatment) to 120 months, the most common being 12 to 24 months. All studies were at overall high risk of bias. Effect of interventions Sealing using sealants versus other interventions for non-cavitated or cavitated but not deep lesions There was insufficient evidence of a difference between sealing with sealants and CR (OR 5.00, 95% CI 0.51 to 49.27; 1 study, 41 teeth, permanent teeth, cavitated), sealing versus SE (OR 3.11, 95% CI 0.11 to 85.52; 2 studies, 82 primary teeth, cavitated) or sealing versus no treatment (OR 0.05, 95% CI 0.00 to 2.71; 2 studies, 103 permanent teeth, non-cavitated), but we assessed all as very low-certainty evidence. HT, CR, SE, NRCC for cavitated, but not deep lesions in primary teeth The odds of failure may be higher for CR than HT (OR 8.35, 95% CI 3.73 to 18.68; 2 studies, 249 teeth; low-certainty evidence) and lower for HT than NRCC (OR 0.19, 95% CI 0.05 to 0.74; 1 study, 84 teeth, very low-certainty evidence). There was insufficient evidence of a difference between SE versus HT (OR 8.94, 95% CI 0.57 to 139.67; 2 studies, 586 teeth) or CR versus NRCC (OR 1.16, 95% CI 0.50 to 2.71; 1 study, 102 teeth), both very low-certainty evidence. CR, SE, SW for deep lesions The odds of failure were higher for CR than SW in permanent teeth (OR 2.06, 95% CI 1.34 to 3.17; 3 studies, 398 teeth; moderate-certainty evidence), but not primary teeth (OR 2.43, 95% CI 0.65 to 9.12; 1 study, 63 teeth; very low-certainty evidence). The odds of failure may be higher for CR than SE in permanent teeth (OR 11.32, 95% CI 1.97 to 65.02; 2 studies, 179 teeth) and primary teeth (OR 4.43, 95% CI 1.04 to 18.77; 4 studies, 265 teeth), both very low-certainty evidence. Notably, two studies compared CR versus SE in cavitated, but not deep lesions, with insufficient evidence of a difference in outcome (OR 0.62, 95% CI 0.21 to 1.88; 204 teeth; very low-certainty evidence). The odds of failure were higher for SW than SE in permanent teeth (OR 2.25, 95% CI 1.33 to 3.82; 3 studies, 371 teeth; moderate-certainty evidence), but not primary teeth (OR 2.05, 95% CI 0.49 to 8.62; 2 studies, 126 teeth; very low-certainty evidence). For deep lesions, a network meta-analysis showed the probability of failure to be greatest for CR compared with SE, SW and HT.

AUTHORS' CONCLUSIONS

Compared with CR, there were lower numbers of failures with HT and SE in the primary dentition, and with SE and SW in the permanent dentition. Most studies showed high risk of bias and limited precision of estimates due to small sample size and typically limited numbers of failures, resulting in assessments of low or very low certainty of evidence for most comparisons.

Knowledge and opinions of French dental students related to caries risk assessment and dental sealants (preventive and therapeutic)

OBJECTIVES

A national questionnaire study was performed to document knowledge and opinions of French dental students (FDSs) about minimal intervention (MI) in dentistry especially caries risk assessment (CRA) and dental sealants (DSs).

MATERIALS AND METHODS

A questionnaire was administered to the fifth-year dental FDSs (n = 1370) from the 16 French dental schools. Descriptive and statistical analyses were performed.

RESULTS

The response rate was 84.5%. A large majority of respondents (87.8%) linked MI with minimally invasive dentistry and 77.4% considered MI as a concept based on prevention. About 80% stated they use CRA in clinical practice, mostly without any specific form. If 80.4% of the respondents would base their treatment plans on CRA, only 55.1% would regularly plan preventive regimens according to individual risk level. However, while 96.6% declared they perform preventive DSs, only 44.3% considered therapeutic sealants as a routine treatment. Although 75.1% of FDSs stated that they had sufficient learning and training related to CRA, 55.9% thought that they need further education about preventive and therapeutic DSs.

CONCLUSION

Although FDSs seem to be aware of the importance of CRA and preventive strategies, this study shows the need to harmonize the teaching in cariology according to the latest European recommendations.

CLINICAL RELEVANCE

A national questionnaire study showed variability towards knowledge and opinions of FDSs related to MI in cariology. This may impact care provisions in their future professional life showing the urgent need to harmonize the teaching of MI in cariology in France.

WITHDRAWN: Operative caries management in adults and children

BACKGROUND

The management of dental caries has traditionally involved removal of all soft demineralised dentine before a filling is placed. However, the benefits of complete caries removal have been questioned because of concerns about the possible adverse effects of removing all soft dentine from the tooth. Three groups of studies have also challenged the doctrine of complete caries removal by sealing caries into teeth using three different techniques. The first technique removes caries in stages over two visits some months apart, allowing the dental pulp time to lay down reparative dentine (the stepwise excavation technique). The second removes part of the dentinal caries and seals the residual caries into the tooth permanently (partial caries removal) and the third technique removes no dentinal caries prior to sealing or restoring (no dentinal caries removal). This is an update of a Cochrane review first published in 2006.

OBJECTIVES

To assess the effects of stepwise, partial or no dentinal caries removal compared with complete caries removal for the management of dentinal caries in previously unrestored primary and permanent teeth.

SEARCH METHODS

The following electronic databases were searched: the Cochrane Oral Health Group's Trials Register (to 12 December 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 11), MEDLINE via OVID (1946 to 12 December 2012) and EMBASE via OVID (1980 to 12 December 2012). There were no restrictions regarding language or date of publication.

SELECTION CRITERIA

Parallel group and split-mouth randomised and quasi-randomised controlled trials comparing stepwise, partial or no dentinal caries removal with complete caries removal, in unrestored primary and permanent teeth were included.

DATA COLLECTION AND ANALYSIS

Three review authors extracted data independently and in triplicate and assessed risk of bias. Trial authors were contacted where possible for information. We used standard methodological procedures exacted by The Cochrane Collaboration.

MAIN RESULTS

In this updated review, four new trials were included bringing the total to eight trials with 934 participants and 1372 teeth. There were three comparisons: stepwise caries removal compared to complete one stage caries removal (four trials); partial caries removal compared to complete caries removal (three trials) and no dentinal caries removal compared to complete caries removal (two trials). (One three-arm trial compared complete caries removal to both stepwise and partial caries removal.) Four studies investigated primary teeth, three permanent teeth and one included both. All of the trials were assessed at high risk of bias, although the new trials showed evidence of attempts to minimise bias.Stepwise caries removal resulted in a 56% reduction in incidence of pulp exposure (risk ratio (RR) 0.44, 95% confidence interval (CI) 0.33 to 0.60, P < 0.00001, I2 = 0%) compared to complete caries removal based on moderate quality evidence, with no heterogeneity. In these four studies, the mean incidence of pulp exposure was 34.7% in the complete caries removal group and 15.4% in the stepwise groups. There was also moderate quality evidence of no difference in the outcome of signs and symptoms of pulp disease (RR 0.78, 95% CI 0.39 to 1.58, P = 0.50, I2 = 0%).Partial caries removal reduced incidence of pulp exposure by 77% compared to complete caries removal (RR 0.23, 95% CI 0.08 to 0.69, P = 0.009, I2 = 0%), also based on moderate quality evidence with no evidence of heterogeneity. In these two studies the mean incidence of pulp exposure was 21.9% in the complete caries removal groups and 5% in the partial caries removal groups. There was insufficient evidence to determine whether or not there was a difference in signs and symptoms of pulp disease (RR 0.27, 95% CI 0.05 to 1.60, P = 0.15, I2 = 0%, low quality evidence), or restoration failure (one study showing no difference and another study showing no failures in either group, very low quality evidence).No dentinal caries removal was compared to complete caries removal in two very different studies. There was some moderate evidence of no difference between these techniques for the outcome of signs and symptoms of pulp disease and reduced risk of restoration failure favouring no dentinal caries removal, from one study, and no instances of pulp disease or restoration failure in either group from a second quasi-randomised study. Meta-analysis of these two studies was not performed due to substantial clinical differences between the studies.

AUTHORS' CONCLUSIONS

Stepwise and partial excavation reduced the incidence of pulp exposure in symptomless, vital, carious primary as well as permanent teeth. Therefore these techniques show clinical advantage over complete caries removal in the management of dentinal caries. There was no evidence of a difference in signs or symptoms of pulpal disease between stepwise excavation, and complete caries removal, and insufficient evidence to determine whether or not there was a difference in signs and symptoms of pulp disease between partial caries removal and complete caries removal. When partial caries removal was carried out there was also insufficient evidence to determine whether or not there is a difference in risk of restoration failure. The no dentinal caries removal studies investigating permanent teeth had a similar result with no difference in restoration failure. The other no dentinal caries removal study, which investigated primary teeth, showed a statistically significant difference in restoration failure favouring the intervention.Due to the short term follow-up in most of the included studies and the high risk of bias, further high quality, long term clinical trials are still required to assess the most effective intervention. However, it should be noted that in studies of this nature, complete elimination of risk of bias may not necessarily be possible. Future research should also investigate patient centred outcomes.

Microcavitated (ICDAS 3) carious lesion arrest with resin or glass ionomer sealants in first permanent molars: A randomized controlled trial

OBJECTIVES

Although there is some consensus that carious lesions in early stages (non-cavitated) could be treated using sealants, neither the type of materials nor their use in lesions with localized enamel breakdown (microcavitated) has been reported To compare the efficacy of resin or glass ionomer (GI) sealants in arresting microcavitated carious lesions (ICDAS 3) in first permanent molars.

MATERIALS AND METHODS

A double-blinded randomized controlled clinical trial was conducted in 41 healthy 6 to 11-year-old children. At the baseline examination, each subject had at least one carious lesion classified as ICDAS 3 on the first permanent molar. One hundred fifty-one lesions were randomized into: Group 1: resin sealants (76 lesions) and Group 2: GI sealant (75 lesions). Carious lesion progression was assessed clinically and radiographically. Progression and retention failure were the outcomes used for group comparisons at p-value<0.05.

RESULTS

After a two-year follow-up, only one lesion progressed to ICDAS 5, without statistically significant differences between the groups (χ²(1) = 0.90, p = 0.53). Radiographically, 100 lesions (98%) were arrested and 2 (2%) showed radiographic progression, without differences between groups (χ²(1) = 0.93, p = 0.93). At 2 years, complete retention was observed in 77% of the resin-based and in 83% of the GI sealants, without statistical differences between type of sealant (χ²(1) = 0.71, p = 0.48). The multilevel mixed model demonstrated that location and type of sealant did not affect retention rates (χ²(1) = 24,98, p < 0.001).

CONCLUSION

Sealing ICDAS 3 carious lesions in permanent molars appears to be effective in arresting lesions after a two-year follow-up. Clinicaltrials.gov: RCTICDAS3/2015.

CLINICAL SIGNIFICANCE

Minimally invasive approaches for carious lesion management have been promoted. Using sealants for the treatment of microcavitated lesions (ICDAS 3) appears predictable in the routine practice, without predilection for resin or glass ionomer materials. In addition to preserving tooth structure, this strategy reduces chair-time, dental fear and costs, and increases coverage to dental care.

Prevalence of Dental Caries and Fissure Sealants in the First Permanent Molars among Male Children in Riyadh, Kingdom of Saudi Arabia

AIMS

To evaluate the prevalence of dental caries and the presence of fissure sealants on the first permanent molars (FPMs) among 6 to 9 years old primary school boys in Riyadh, Kingdom of Saudi Arabia.

MATERIALS AND METHODS

The carious status and the presence of fissure sealants on the FPMs were examined in 1844 schoolboys, aged 6-9 years (the first three grades), from 17 randomly selected primary schools in Riyadh city, Kingdom of Saudi Arabia.Chi-square test was used to assess the significance of differences in prevalence and proportions.

RESULTS

A total of 5394 FPMs were assessed in the 1844 children. Eighty-three point five percent of children were caries free. Only 0.8% of the children had at least one fissure sealant applied. At tooth level, the decayed FPMs counted for 10.6%. There was obvious underuse of fissure sealants on the FPMs; 0.5% (n = 25). The caries prevalence in the mandibular FPMs (14.4%), was significantly higher than in the maxillary FPMs, 7.7% (p < 0.01). The proportion of carious FPMs increased with age of the children significantly (p < 0.01). There was no significant difference in the proportion of the presence of fissure sealants among the three different grade/age groups (p > 0.05).

CONCLUSION

Caries prevalence in the FPMs was moderate but serious amongst this cohort of young students. This was opposed with very low use of fissure sealants.

CLINICAL SIGNIFICANCE

Careful examination of the first permanent molars among children is mandatory because of their high caries susceptibility. It is important to increase public and dental professionals' awareness of the effectiveness of fissure sealants and encouraging more placement.How to cite this article: Aldossary MS, Alamri AA, Alshiha SA, Hattan MA, Alfraih YK, Alwayli HM. Prevalence of Dental Caries and Fissure Sealants in the First Permanent Molars among Male Children in Riyadh, Kingdom Saudi Arabia. Int J Clin Pediatr Dent., 2018;11(5):365-370.

Pit and Fissure Sealants-A Comprehensive Review

Even in the 21st century, dental caries is considered a global burden, severely upsetting the health and quality of life of those affected. Apart from the usage of fluoride and regular oral hygiene, one of the most important prophylactic approaches against the occurrence of caries is the sealing of pits and fissures. However, the rapid progress of new materials and applications for sealing pits and fissures also raises new questions about their correct application. Recent literature on pit and fissure sealing, caries prevention, as well as caries risk assessment for both children and adults was reviewed. This report provides a general overview of pit and fissure sealing, the materials used for sealing occlusal surfaces, as well as indications and possible side effects. The conclusions are that sealing pit and fissures of primary and permanent teeth is an effective method for preventing and arresting caries. However, regular checkups must be conducted to avoid advanced tooth decay attributable to leakages in the sealing.

Efficacy of sealing occlusal caries with a flowable composite in primary molars: A 2-year randomized controlled clinical trial

OBJECTIVES

This randomized controlled clinical trial evaluated the efficacy of sealing carious dentin in controlling the progression of lesions in primary molars for 2-year follow-up.

MATERIALS AND METHODS

Children (6.79 ± 1.81 years, n = 28) presenting primary molars with occlusal caries in the outer half of dentine were randomized and allocated into 2 groups: test (sealing caries with a flowable resin - SC) and control (partial removal of caries followed by restoration - PRC). The primary outcomes were: the clinical success of restorations evaluated by USPHS criteria and the radiographic analysis of caries progression. The children anxiety was evaluated by a Facial Image Scale; and the time required to perform the treatments was registered.

RESULTS

In 21 patients evaluated after 2 years, 48 primary molars were analyzed. Clinically, there was no difference between the groups. There was no difference between treatments (p = 0.848) considering lesion progression. The anxiety level did not change after the two interventions (p = 0.650). The treatment time of SC (9.03 ± 1.91 min) was lower (p = 0.002) than the PRC time (17.13 ± 5.26 min).

CONCLUSION

Sealing carious dentin may be used in dentistry since it did not alter the children anxiety, reduced the chair time and demonstrated clinical success rate and no radiographic difference in relation to the partial caries removal followed by restoration.

A survey of fissure sealants and dental caries prevalence in the first permanent molars among primary school girls in Riyadh, Saudi Arabia

Objectives:

To investigate the prevalence of caries and fissure sealants on the first permanent molars (FPMs) among 6–9-year-old girls in Riyadh, Saudi Arabia.

Materials and Methods:

The FPMs of 17,891 school girls from 120 randomly selected public primary schools were evaluated by visual and tactile examination for the carious status and the presence of fissure sealants. Chi-square test was used to analyze the data at level of 5%.

Results:

A total of 58,140 FPMs were assessed in the 17,891 children. Nearly 64.6% of the children were caries free. Only 1.3% of the children had at least one fissure sealant applied. At tooth level, the decayed FPMs counted for 24.6%. There was obvious underutilization of fissure sealants on the FPMs; 0.8% (n = 478). The caries prevalence in the mandibular FPMs (33%) was significantly higher than in the maxillary FPMs, 18.2% (P < 0.01). The proportion of carious FPMs increased with age of the children significantly (P < 0.01). There was no significant difference in the proportion of the presence of fissure sealants among the three different grade/age groups (P > 0.05).

Conclusions:

Caries prevalence in the FPMs was high and serious among this cohort of young students. This was contrasting the very low prevalence of fissure sealants.

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.

Managing caries: the need to close the gap between the evidence base and current practice

Underpinned by a changing knowledge of the aetiology of caries and its sequelae, and assisted by established and advancing dental materials, there is growing evidence supporting less invasive management of dental caries based on the principles of minimal intervention dentistry. This narrative review assesses both the evidence and the adoption of less invasive caries management strategies and describes ways in which the gap between evidence and practice might be overcome. While there is increasing data supporting less invasive management of carious lesions, these are not standard in most dental practices worldwide. Usually, clinical studies focused on efficacy as outcome, and did not take into consideration the views and priorities of other stakeholders, such as primary care dentists, educators, patients and those financing services. Involving these stakeholders into study design and demonstrating the broader advantages of new management strategies might improve translation of research into practice. In theory, clinical dentists can rely on a growing evidence in cariology regarding less invasive management options. In practice, further factors seem to impede adoption of these strategies. Future research should address these factors by involving major stakeholders and investigating their prioritised outcomes to narrow or close the evidence gap.

Minimal intervention dentistry II: part 3. Management of non-cavitated (initial) occlusal caries lesions--non-invasive approaches through remineralisation and therapeutic sealants

Epidemiological data on dental caries show that prevention and treatment needs have evolved significantly over the past two decades. In younger patients the distribution of caries lesions is mainly found on the occlusal surfaces. The treatment approaches utilised by dentists must evolve to integrate preventive and treatment solutions tailored to the care needs, which are straightforward to implement in the dental office and whose effectiveness is underpinned by scientific evidence. This article aims to describe the principles of non-invasive management of non-cavitated (initial) occlusal caries lesions, based on evidence from recent studies published in the international literature.

Marginal and internal analysis of preheated dental fissure-sealing materials using optical coherence tomography

OBJECTIVES

This study aimed to evaluate the influence of pre-photoactivation temperature on the marginal and internal integrity (occurrence of voids) of fissure-sealing materials on occlusal fissures using optical coherence tomography (OCT).

METHODS

Occlusal fissures of 40 human third molars were sealed using a resin-based fissure sealant (Fluroshield) and a flowable composite (Permaflo) photoactivated at 68 °C (preheated) or at room temperature (25 °C) (n=10). After sealing, the teeth were subjected to thermocycling (500 cycles, 5-55 °C) and 14 days of pH cycling (demineralisation for 6 hours/day and remineralisation for 18 hours/day). The occlusal surfaces were scanned in a buccolingual direction, and 20 tomographic images parallel to the long axis of each tooth were obtained. Images presenting marginal gaps and internal voids were counted and statistically analysed using analysis of variance and Tukey's test (P<0.05).

RESULTS

There were statistically significant differences between materials and temperatures (P<0.01). The flowable composite had a lower percentage of gaps and internal voids than the resin-based sealant. Preheated materials had a lower percentage of gaps and internal voids than the materials at room temperature.

CONCLUSION

Therefore, preheated flowable composite provided the best marginal sealing of fissures, and internal homogeneity of the material.

Seal, replacement or monitoring amalgam restorations with occlusal marginal defects? Results of a 10-year clinical trial

The aim of this prospective and blind clinical trial was to assess the effectiveness of sealing localized marginal defects of amalgam restoration that were initially scheduled to be replaced. A cohort of twenty six patients with 60 amalgam restorations (n=44Class I and n=16Class II), that presented marginal defects deviating from ideal (Bravo) according to USPHS criteria, were assigned to either sealing or replacement groups: A: sealing n=20, Replacement n=20, and no treatment (n=20). Two blind examiners evaluated the restorations at baseline (K=0.74) and after ten years (K=0.84) according with USPHS criteria, in four parameters: marginal adaptation (MA), secondary caries (SC), marginal staining (MS) and teeth sensitivity (TS). Multiple comparison of restorations degradation/upgrade was analyzed by Friedman test and the comparisons within groups were performed by Wilcoxon test. After 10 years, 44 restorations were assessed (73.3%), Group A: n=14 and Group B: n=16; and Group C: n=14 sealing and replacement amalgam restorations presented similar level of quality in MA (p=0.76), SC (p=0.25) and TS (p=0.52), while in MS (p=0.007) presented better performance in replacement group after 10-years. Most of the occlusal amalgam restorations with marginal gaps showed similar long term outcomes than the restorations were sealed, replaced, or not treated over a 10-year period. Most of the restorations of the three groups were clinically acceptable, under the studied parameters. All restorations had the tendency to present downgrade/deterioration over time.

Prevalence of dental caries and fissure sealants in a Portuguese sample of adolescents

INTRODUCTION

The aims of this study were to assess the prevalence of dental caries and the DMFT index, as well as the distribution pattern of pit and fissure sealants on permanent teeth in a Portuguese sample of adolescents, and to assess whether the existing usage of sealants and socio-demographic factors are correlated to caries prevalence on the examined sample.

MATERIALS AND METHODS

A cross-sectional study was designed with a sample of 447 adolescents aged 12 to 18 years old, attending a public school in Sátão, Portugal. A self-administered questionnaire with questions about oral health behaviours and socio-economic status was answered by adolescents in the classroom. Clinical examination of oral health status and assessment of fissure sealants were accomplished by only one trained member of the research team.

RESULTS

We obtained a DMFT index of 3.32 (2.92), which indicates a moderate level of prevalence of dental caries. When considering a DMFT = 0, we found significant statistical differences between the parents' level of education (≤ 4th grade = 26.3 vs 5th-12th grade = 18.8 vs <12th grade = 43.3, p = 0.001), gender (male = 27.3 vs female = 19.6, p = 0.04), age (≤ 15 years = 27.1 vs <15 years = 18.5, p = 0.02), presence of fissure sealants (yes = 30.6 vs no = 13.5, p = 0.001) and experience of dental pain (no = 25.4 vs yes = 16.8, p = 0.02). When analyzing the prevalence of fissure sealants, we verified that 58.8% of adolescents had at least one fissure sealant applied. Significant statistical differences were found when analyzing the presence of fissure sealants related with parents' educational level (<9th grade, OR = 1.56 CI95% = 1.05-2.54), gender (female, OR = 1.86 CI95% = 1.19-2.98), experience of dental pain (yes, OR = 0.62 CI95% = 0.39-0.97) and presence of dental caries (yes, OR = 0.35 CI95% = 0.19-0.65).

CONCLUSIONS

The moderate level of caries prevalence reveals the need of improvement of primary prevention interventions among Portuguese adolescents. The establishment of a more targeted preventive program with better and more effective oral health education is essential, having into account socio-demographic aspects.

Treating pit-and-fissure caries: a systematic review and network meta-analysis

For shallow or moderately deep pit-and-fissure lesions, various treatment options are available: (1) noninvasive treatments (e.g., fluoride application, antibacterial treatments, oral hygiene advice) avoid any dental hard tissue removal; (2) microinvasive treatments (e.g., sealing) remove only a few micrometers of hard tissues by etching; and minimally invasive methods (e.g., "preventive" resin/sealant restoration) remove carious dentin but avoid sacrificing sound tissues. We aimed at systematically reviewing and comparing these strategies for treating pit-and-fissure lesions in permanent teeth using network meta-analysis. Randomized or nonrandomized clinical trials investigating shallow or moderately deep primary caries lesions in fissured or pitted surfaces were included. We compared the risk of requiring invasive treatments or any retreatments in noninvasive, microinvasive, and minimally invasive treated lesions; untreated lesions were used as controls. Five electronic databases were systematically screened up to September 2013 and cross-referencing performed. Pairwise and network meta-analyses were performed and odds ratios and 95% confidence intervals (CI) calculated. Certainty of estimates was evaluated via GRADE criteria. From a total of 2,214 identified records, 14 studies representing 1,440 patients with 3,551 treated lesions were included. Pairwise meta-analysis found microinvasive and minimally invasive treated lesions to require less invasive retreatments than control lesions (odds ratios [95% confidence intervals]: 0.13 [0.07 to 0.26], 0.13 [0.03 to 0.50], respectively), whereas the estimate for noninvasively treated lesions remained nonsignificant (0.64 [0.39 to 1.06]). These findings were reflected in the strategy ranking stemming from network meta-analysis (first, minimally invasive; second, microinvasive; third, noninvasive). However, microinvasive treatment required significantly more total retreatments (including resealing) than minimally or noninvasive treatments. Due to limited study quality, the evidence was graded as low or very low. Clinical treatment decisions should consider the long-term sequelae and costs stemming from different therapies as well as their subjective impact on the patient. Available treatment options seem suitable for treating shallow or moderately deep pit-and-fissure lesions in permanent teeth; further conclusions are not possible.

Detecting and treating occlusal caries lesions: a cost-effectiveness analysis

The health gains and costs resulting from using different caries detection strategies might not only depend on the accuracy of the used method but also the treatment emanating from its use in different populations. We compared combinations of visual-tactile, radiographic, or laser-fluorescence-based detection methods with 1 of 3 treatments (non-, micro-, and invasive treatment) initiated at different cutoffs (treating all or only dentinal lesions) in populations with low or high caries prevalence. A Markov model was constructed to follow an occlusal surface in a permanent molar in an initially 12-y-old male German patient over his lifetime. Prevalence data and transition probabilities were extracted from the literature, while validity parameters of different methods were synthesized or obtained from systematic reviews. Microsimulations were performed to analyze the model, assuming a German health care setting and a mixed public-private payer perspective. Radiographic and fluorescence-based methods led to more overtreatments, especially in populations with low prevalence. For the latter, combining visual-tactile or radiographic detection with microinvasive treatment retained teeth longest (mean 66 y) at lowest costs (329 and 332 Euro, respectively), while combining radiographic or fluorescence-based detections with invasive treatment was the least cost-effective (<60 y, >700 Euro). In populations with high prevalence, combining radiographic detection with microinvasive treatment was most cost-effective (63 y, 528 Euro), while sensitive detection methods combined with invasive treatments were again the least cost-effective (<59 y, >690 Euro). The suitability of detection methods differed significantly between populations, and the cost-effectiveness was greatly influenced by the treatment initiated after lesion detection. The accuracy of a detection method relative to a "gold standard" did not automatically convey into better health or reduced costs. Detection methods should be evaluated not only against their criterion validity but also the long-term effects resulting from their use in different populations.

Sealing versus partial caries removal in primary molars: a randomized clinical trial

BACKGROUND

The resin-based pit and fissure sealant is considered a successful tool in caries prevention, however there is a growing evidence of its use in controlling already established caries in posterior teeth. The aim of this clinical trial is to verify the efficacy of pit and fissure sealants in arresting dentinal caries lesions compared to partial excavation and restorative treatment in primary molar teeth.

METHODS

Thirty six patients with occlusal cavitated primary molar reaching outer half of dentin were selected. The patients were randomly allocated into two groups: sealant application (experimental group - n = 17) and restoration with composite resin (control group - n = 19). Clinical and radiograph evaluation were performed after 6, 12 and 18 months. The chi-square test was used to verify the distribution of characteristics variables of the sample among the groups. The survival rate of treatments was evaluated using Kaplan-Meier survival and log-rank test. Fisher's Exact and logistic regression tests were calculated in each evaluation period (α = 5%).

RESULTS

The control group showed significantly better clinical survival after 18 months (p = 0.0025). In both groups, no caries progression was registered on the radiographic evaluations.

CONCLUSIONS

Sealing had similar efficacy in the arrestment of caries progression of cavitated occlusal lesions compared to partial excavation of the lesions, even though the frequency of re-treatments was significantly higher in sealed lesions.

TRIAL REGISTRATION

Registro Brasileiro de Ensaios Clínicos (ReBEC): RBR-9kkv53.

Operative caries management in adults and children

BACKGROUND

The management of dental caries has traditionally involved removal of all soft demineralised dentine before a filling is placed. However, the benefits of complete caries removal have been questioned because of concerns about the possible adverse effects of removing all soft dentine from the tooth. Three groups of studies have also challenged the doctrine of complete caries removal by sealing caries into teeth using three different techniques. The first technique removes caries in stages over two visits some months apart, allowing the dental pulp time to lay down reparative dentine (the stepwise excavation technique). The second removes part of the dentinal caries and seals the residual caries into the tooth permanently (partial caries removal) and the third technique removes no dentinal caries prior to sealing or restoring (no dentinal caries removal). This is an update of a Cochrane review first published in 2006.

OBJECTIVES

To assess the effects of stepwise, partial or no dentinal caries removal compared with complete caries removal for the management of dentinal caries in previously unrestored primary and permanent teeth.

SEARCH METHODS

The following electronic databases were searched: the Cochrane Oral Health Group's Trials Register (to 12 December 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 11), MEDLINE via OVID (1946 to 12 December 2012) and EMBASE via OVID (1980 to 12 December 2012). There were no restrictions regarding language or date of publication.

SELECTION CRITERIA

Parallel group and split-mouth randomised and quasi-randomised controlled trials comparing stepwise, partial or no dentinal caries removal with complete caries removal, in unrestored primary and permanent teeth were included.

DATA COLLECTION AND ANALYSIS

Three review authors extracted data independently and in triplicate and assessed risk of bias. Trial authors were contacted where possible for information. We used standard methodological procedures exacted by The Cochrane Collaboration.

MAIN RESULTS

In this updated review, four new trials were included bringing the total to eight trials with 934 participants and 1372 teeth. There were three comparisons: stepwise caries removal compared to complete one stage caries removal (four trials); partial caries removal compared to complete caries removal (three trials) and no dentinal caries removal compared to complete caries removal (two trials). (One three-arm trial compared complete caries removal to both stepwise and partial caries removal.) Four studies investigated primary teeth, three permanent teeth and one included both. All of the trials were assessed at high risk of bias, although the new trials showed evidence of attempts to minimise bias.Stepwise caries removal resulted in a 56% reduction in incidence of pulp exposure (risk ratio (RR) 0.44, 95% confidence interval (CI) 0.33 to 0.60, P < 0.00001, I(2) = 0%) compared to complete caries removal based on moderate quality evidence, with no heterogeneity. In these four studies, the mean incidence of pulp exposure was 34.7% in the complete caries removal group and 15.4% in the stepwise groups. There was also moderate quality evidence of no difference in the outcome of signs and symptoms of pulp disease (RR 0.78, 95% CI 0.39 to 1.58, P = 0.50, I(2) = 0%).Partial caries removal reduced incidence of pulp exposure by 77% compared to complete caries removal (RR 0.23, 95% CI 0.08 to 0.69, P = 0.009, I(2) = 0%), also based on moderate quality evidence with no evidence of heterogeneity. In these two studies the mean incidence of pulp exposure was 21.9% in the complete caries removal groups and 5% in the partial caries removal groups. There was insufficient evidence to determine whether or not there was a difference in signs and symptoms of pulp disease (RR 0.27, 95% CI 0.05 to 1.60, P = 0.15, I(2) = 0%, low quality evidence), or restoration failure (one study showing no difference and another study showing no failures in either group, very low quality evidence).No dentinal caries removal was compared to complete caries removal in two very different studies. There was some moderate evidence of no difference between these techniques for the outcome of signs and symptoms of pulp disease and reduced risk of restoration failure favouring no dentinal caries removal, from one study, and no instances of pulp disease or restoration failure in either group from a second quasi-randomised study. Meta-analysis of these two studies was not performed due to substantial clinical differences between the studies.

AUTHORS' CONCLUSIONS

Stepwise and partial excavation reduced the incidence of pulp exposure in symptomless, vital, carious primary as well as permanent teeth. Therefore these techniques show clinical advantage over complete caries removal in the management of dentinal caries. There was no evidence of a difference in signs or symptoms of pulpal disease between stepwise excavation, and complete caries removal, and insufficient evidence to determine whether or not there was a difference in signs and symptoms of pulp disease between partial caries removal and complete caries removal. When partial caries removal was carried out there was also insufficient evidence to determine whether or not there is a difference in risk of restoration failure. The no dentinal caries removal studies investigating permanent teeth had a similar result with no difference in restoration failure. The other no dentinal caries removal study, which investigated primary teeth, showed a statistically significant difference in restoration failure favouring the intervention.Due to the short term follow-up in most of the included studies and the high risk of bias, further high quality, long term clinical trials are still required to assess the most effective intervention. However, it should be noted that in studies of this nature, complete elimination of risk of bias may not necessarily be possible. Future research should also investigate patient centred outcomes.