Seal or Varnish? A randomised controlled trial to determine the relative cost and effectiveness of pit and fissure sealant and fluoride varnish in preventing dental decay

Background Fissure sealant (FS) and fluoride varnish (FV) have been shown to be effective in preventing dental caries when tested against a no-treatment control. However, the relative clinical effectiveness and cost-effectiveness of these interventions is unknown. Objective To compare the clinical effectiveness and cost-effectiveness of FS and FV in preventing dental caries in first permanent molars (FPMs) in 6- and 7-year-olds and to determine their acceptability. Design A randomised controlled allocation-blinded clinical trial with two parallel arms. Setting A targeted population programme using mobile dental clinics (MDCs) in schools located in areas of high social and economic deprivation in South Wales. Participants In total, 1016 children were randomised, but one parent subsequently withdrew permission and so the analysis was based on 1015 children. The randomisation of participants was stratified by school and balanced for sex and primary dentition baseline caries levels using minimisation in a 1 : 1 ratio for treatments. A random component was added to the minimisation algorithm, such that it was not completely deterministic. Of the participants, 514 were randomised to receive FS and 502 were randomised to receive FV. Interventions Resin-based FS was applied to caries-free FPMs and maintained at 6-monthly intervals. FV was applied at baseline and at 6-month intervals over the course of 3 years. Main outcome measures The proportion of children developing caries into dentine (decayed, missing, filled teeth in permanent dentition, i.e. D4–6MFT) on any one of up to four treated FPMs after 36 months. The assessors were blinded to treatment allocation; however, the presence or absence of FS at assessment would obviously indicate the probable treatment received. Economic measures established the costs and budget impact of FS and FV and the relative cost-effectiveness of these technologies. Qualitative interviews determined the acceptability of the interventions. Results At 36 months, 835 (82%) children remained in the trial: 417 in the FS arm and 418 in the FV arm. The proportion of children who developed caries into dentine on a least one FPM was lower in the FV arm (73; 17.5%) than in the FS arm (82, 19.6%) [odds ratio (OR) 0.84, 95% confidence interval (CI) 0.59 to 1.21; p = 0.35] but the difference was not statistically significant. The results were similar when the numbers of newly decayed teeth (OR 0.86, 95% CI 0.60 to 1.22) and tooth surfaces (OR 0.85, 95% CI 0.59 to 1.21) were examined. Trial fidelity was high: 95% of participants received five or six of the six scheduled treatments. Between 74% and 93% of sealants (upper and lower teeth) were intact at 36 months. The costs of the two technologies showed a small but statistically significant difference; the mean cost to the NHS (including intervention costs) per child was £500 for FS, compared with £432 for FV, a difference of £68.13 (95% CI £5.63 to £130.63; p = 0.033) in favour of FV. The budget impact analysis suggests that there is a cost saving of £68.13 (95% CI £5.63 to £130.63; p = 0.033) per child treated if using FV compared with the application of FS over this time period. An acceptability score completed by the children immediately after treatment and subsequent interviews demonstrated that both interventions were acceptable to the children. No adverse effects were reported. Limitations There are no important limitations to this study. Conclusions In a community oral health programme utilising MDCs and targeted at children with high caries risk, the twice-yearly application of FV resulted in caries prevention that is not significantly different from that obtained by applying and maintaining FSs after 36 months. FV proved less expensive. Future work The clinical effectiveness and cost-effectiveness of FS and FV following the cessation of active intervention merits investigation

Occlusal caries detection in permanent molars according to WHO basic methods, ICDAS II and laser fluorescence measurements

This epidemiological study aimed to compare the diagnostic outcome of the WHO criteria, ICDAS II criteria, laser fluorescence measurements, presence of plaque and roughness as activity scores on occlusal fissures and buccal/palatal pits of the first permanent molars. The study involved 311 children between 8 and 12 years of age from the Ennepe-Ruhr District in North Rhine-Westphalia, Germany. The surface-related caries status was registered according to the WHO basic method criteria (1997). Additionally, pit and fissure sealants, the ICDAS II visual criteria, the DIAGNOdent reading, plaque retention and surface roughness were documented. Caries experience was 1.0 (+/- 2.5) DMFS. About 70% of the examined students had no obvious dentin caries in the permanent dentition (DMFS = 0). Sealants were registered on 1.4 (+/- 1.7) occlusal fissures and 0.4 (+/- 0.9) palatal/buccal pits. Noncavitated caries lesions were recorded as ICDAS II score 1-4 on 1.8 (+/- 1.6) fissures and 1.5 (+/- 1.4) pits. The comparison of the diagnostic methods suggests a relationship between higher ICDAS II scores/DIAGNOdent values and a proportional increase in the occurrence of plaque as well as in the number of rough surfaces. In conclusion, this study showed the diagnostic potential of the ICDAS II criteria in comparison to the traditional WHO criteria by means of the noncavitated caries lesions additionally detected. The DIAGNOdent use in field studies that already apply detailed visual criteria seems to bring limited additional information. While the presence of plaque provides information for the caries activity assessment more work is required to provide information about the contribution of surface roughness.</p

A Systematic Review of Dental Recall Intervals and Incidence of Dental Caries

Background. Dental recall interval protocols are used to prevent dental disease through regular maintenance evaluations and preventive procedures. In this systematic review, the authors examined the evidence for the rationale behind a one-recall-interval-fits-all\u27\u27 protocol, such as a six-month recall interval on caries incidence. Methods. The authors searched the PubMed database and reviewed titles, abstracts and full reports. They also searched the references of each full report and used the Related articles feature. They used a checklist validated for randomized and nonrandomized studies to conduct a quality assessment for each article. Results. The authors found seven articles representing six studies that met their inclusion criteria. The results of a randomized controlled trial showed no significant differences in oral health between patients recalled every 12 months and those recalled every 24 months. The investigators of one nonrandomized controlled trial reported that a two- to three-month recall interval significantly reduced the incidence and recurrence of caries. The investigators of an additional longitudinal nonrandomized controlled study that compared three-, six- and 12-month recall intervals reported caries increments of 4.4,4.0 and 4.9, respectively. The results of two retrospective studies showed that a specific recall interval did not alter caries incidence significantly. The results from a cross-sectional study suggested that a sixmonth recall interval was associated with more restored teeth but less active caries. Conclusions. The authors conclude that the evidence for using a one-recallinterval-fits-all protocol to reduce caries incidence was weak. Studies that addressed the impact of recall interval on caries incidence were methodologically weak. The evidence was not strong enough to support using any specific one-recallinterval-fits-all protocol for all patients. Clinical Implications. Using a one-recall-interval-fits-all protocol for caries prevention should be re-evaluated. On the basis of evidence from the randomized controlled trial, recall intervals could be extended to every two years. Evidence from the other studies revealed conflicting results for the efficacy of using any specific recall interval protocol. Because all of these studies had serious threats to validity, clinicians may wish to consider assigning recall intervals to patients on the basis of the patients\u27 risk of developing caries. However, a discussion of a caries risk assessment is beyond the scope of this review

Clinical comparison of a flowable composite and fissure sealant: A 24-month split-mouth, randomized, and controlled study

Objectives: The aim of this clinical study was to evaluate the retention rate and caries-prevention effect of a flowable composite compared to a conventional resin-based sealant in a young population over a 24-month period