Pit and fissure sealants for preventing dental decay in permanent teeth

Anneli Ahovuo‐Saloranta, Helena Forss, Tanya Walsh, Anne Nordblad, Marjukka Mäkelä, Helen V Worthington

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