THERAPY

ARTICLE ANALYSIS & EVALUATION

Glass Ionomer Pit andFissure Sealant Provides Caries

Protection on Occlusal Surfaces

ARTICLE TITLE ANDBIBLIOGRAPHICINFORMATION

Caries-Preventive Effect of a One-Time Application of CompositeResin and Glass Ionomer SealantsAfter 5 YearsBeiruti N, Frencken JE, et al.Caries Res 2006;40(1):52-9

LEVEL OF EVIDENCE

1c

PURPOSE/QUESTION

To compare the caries-preventiveeffect of glass ionomer sealantsplaced according to the atraumaticrestorative treatment (ART)procedure with that for compositeresin sealants over a 5-year period;and to investigate the cariespreventive effect after completedisappearance of sealant material.

SOURCE OF FUNDING

Government of The Netherlandsthrough the World HealthOrganization Global ART Projectand Dental Health InternationalNetherlands; also, industry:3MESPE and GC America

TYPE OF STUDY/DESIGN

Randomized Controlled Trial

J Evid Base Dent Pract 2007;7:12-131532-3382/$35.00© 2007 Elsevier Inc. All rights reserved.

doi:10.1016/j.jebdp.2006.12.005

SUMMARY

SubjectsThe subjects were 46 boys and 57 girls from Damascus, Syria, with a meanage of 7.8 years with virgin occlusal surfaces on permanent molar teeth.The gender distribution was reported as “almost” 45% males and “almost”55% females in each group with an overall mean of 7.8 years with no agerange given. The children were selected because in a prior study thesechildren had no cavitated dentine lesions in their primary teeth. The studywas performed between 1997 and 2002. Additional selection criteria were(1) sound occlusal surfaces in fully erupted permanent molars, and (2) pitsand fissures diagnosed with early enamel lesion and/or small dentinelesion. Exclusion criteria were (1) partly erupted first molar, (2) an obviouscavity in the occlusal surface, and (3) presence of restoration or sealant inthe pit and fissure system.

TherapyA total of 53 children with 180 occlusal surfaces were randomly assigned tothe composite resin sealant group (Visio-Seal, ESPE, Minneapolis, MN)and 50 children with 180 occlusal surfaces were enrolled in the glassionomer sealant group (FUJI IX, GC America, Alsip, IL). A single “expe-rienced” oral hygienist placed the sealants without chairside assistance in awell-equipped operatory. This “experienced” oral hygienist was experi-enced in placing composite resin sealants, but had no prior experienceplacing the glass ionomer sealants (ART technique). There was no men-tion of a training session for this individual before onset of the study. Onlypits and fissures in occlusal surfaces of first molars were sealed.

Sealant coverage for the composite resin or the glass ionomer (intact ornot) was not recorded at baseline.

Main Outcome MeasureThe primary outcome measures were (1) retention or loss of the sealants,and (2) caries development over time after sealant loss. The children wereevaluated by several examiners after 1, 2, 3, 4, and 5 years for whether thesealants were completely present (no pits and fissures visible); part of pitsand fissures visible; or all pits and fissures were visible. Presence of absenceof caries was noted. The occlusal surfaces were divided into mesial, central,and distal “sections” for evaluation. Complete loss of sealant was consid-ered only if all 3 sections of an occlusal surface had no remaining visiblesealant or if a restoration had been placed. The method of evaluation(visual vs tactile) is not defined. No radiographs were taken. Teeth with lostsealants were followed without reapplication of the sealants and cariesformation was noted over time.

Main ResultsThe percentage of sealed teeth lost to followup was less than 1% at 1 year,

12% at 2 years, 17% at 3 years, 21% at 4 years, and 48% at 5 years. At the

JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE

end of the 5-year period, 86% of composite resins and88% of glass ionomers did not survive (complete loss ofmaterial). At 1 year after sealant loss, dentine lesions werenoted in 0.8% of the group with glass ionomer sealantsand 3.9% of the group with composite resin sealants(statistically significant). At 5 years after sealant loss, den-tine lesions were noted in 3.3% of the group with glassionomer sealants and 12.8% of the group with compositeresin sealants (statistically significant).

ConclusionsThe reported findings were (1) glass ionomer sealantsapplied with the ART had a 3.1 to 4.5 times highercaries-preventive effect when compared with that forcomposite resin sealants after 3 to 5 years; and (2) glassionomer sealants had a 4 times higher chance of prevent-ing caries development in pit and fissures with sealant lossthan composite resin sealants over a 1- to 3-year period.

COMMENTARY AND ANALYSIS

Although this clinical study provided encouraging results,there are certain concerns. The subjects were selectedbased on the lack of dentinal lesions in their primarydentition. This would imply these children are at rela-tively low risk for caries development. The inclusion cri-teria also required complete eruption of the first molarteeth into the oral cavity. There was substantial loss ofsubjects during the 5-year study period.

The high rate of sealant loss for the composite resinsealant group is quite unexpected, with less than 15% ofcomposite sealants being retained and only 13% of glassionomer sealants being retained. There was more than85% complete loss of sealant material in both groups.This raises a concern for the composite resin sealantplacement technique used by the single oral hygienist,especially considering that a well-equipped operatory wasprovided. This raises an issue of whether the data can beapplied to the typical clinical situation or only to subop-timal field conditions where ART would typically be used.It is also not certain why the investigators decided toevaluate the teeth by dividing the occlusal surface into 3sections (mesial, central, and distal). Complete retention,partial loss, and complete loss of sealant have been astandard method for evaluating occlusal surfaces for sev-eral decades. The addition of mesial, central, and distalsections of the occlusal surface would seem to add datapoints without adding clinically meaningful information.

The Visio-Seal composite resin sealant is no longerproduced by the manufacturer, and there are no clinicalstudies regarding caries development and sealant reten-

tion. It is not known if the material was effective at

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preventing caries, or if it was retained as well as otherwell-established composite resin sealants currently beingused in dental practice. The reason for withdrawal fromthe market is not known.

Within the discussion, the authors address several ofthese issues and provided logical reasons for the prob-lems associated with the study design and findings. Theauthors also pointed out the high loss of both glass iono-mer and composite resin sealants compared with thatcommonly reported in the literature.

The 1-time application of glass ionomer and compositeresin sealants, and following those teeth that lost theirsealants for development of caries may not be standard ofcare to some clinicians. The patient population that re-turned for follow-up examinations extending up to 5years probably would have had little to no dentine lesionshad reapplication of the sealant materials been per-formed as typically occurs in dental practices.

The present study is intended to compare ART usingglass ionomer with composite resin sealants. The ability ofglass ionomer sealants to provide a significant degree ofcaries prevention is well known and again illustratedwithin this study. The use of glass ionomer sealantsshould be encouraged to prevent caries in children withcaries-susceptible pits and fissures.

SUGGESTED READING

1. Simonsen RJ. Pit and fissure sealants: review of the literature. PediatrDent 2002;24:393-414.

2. Simonsen RJ. Glass ionomers as fissure sealants—a critical review. JPublic Health Dent 1996;56:146-9.

3. Frencken JE, Makoni F, Sithole ES. ART restoration and glass iono-mer sealants in Zimbabwe: survival after 3 years. Community DentOral Epidemiol 1998;26:372-81.

4. Holmgren CJ, Lo ECM, Hu DY, Wann HC. ART restorations andsealants placed in Chinese school children—results after 3 years.Community Dent Oral Epidemiol 2000;28:314-20.

5. Peretz B, Ram S, Azo E, Efat Y. Preschool caries as an indicator offuture caries: a longitudinal study. Pediatr Dent 2003;25:114-8.

6. Hicks J, Flaitz C. Pit and fissure sealants and conservative adhesiverestorations: scientific and clinical rationale. In: Pinkham JR, Casa-massimo PS, Fields HW, McTigue DJ, Nowak AJ, eds. PediatricDentistry—Infancy through Adolescence. 4th ed. Philadelphia, PA:Elevier Saunders Publishing; 2005:520-76.

REVIEWER

John Hicks, MD, DDS, MS, PhDDepartment of PathologyTexas Children’s Hospital andBaylor College of MedicineHouston, TX 77030

mjhicks@texaschildrenshospital.org

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