Caries-preventive effect of fissure sealants: A systematic review

Abstract

The objectives of this study were to evaluate systematically the evidence of the caries-preventive effect of fissure sealing of occlusal tooth surfaces and to examine factors potentially modifying the effect. The search strategies included electronic databases, reference lists of articles, and selected textbooks. Inclusion criteria were randomized or quasi-randomized clinical trials or controlled clinical trials comparing fissure sealing with no treatment or another preventive treatment in children up to 14 years of age at the start; the outcome measure was caries increment; the diagnostic criteria had been described; and the follow-up time was at least 2 years. Inclusion decisions were taken and grading of the studies was done independently by two of the authors. The main measure of effect was relative risk reduction. Thirteen studies using resin-based or glass ionomer sealant materials were included in the final analysis. The results showed that most studies were performed during the 1970s and a single application had been utilized. The relative caries risk reduction pooled estimate of resin-based sealants on permanent 1st molars was 33% (relative risk = 0.67; CI = 0.55-0.83). The effect depended on retention of the sealant. In conclusion, the review suggests limited evidence that fissure sealing of 1st permanent molars with resin-based materials has a caries-preventive effect. The evidence is incomplete for permanent 2nd molars, premolars and primary molars and for glass ionomer cements. Overall, there remains a need for further trials of high quality, particularly in child populations with a low and a high caries risk, respectively.

Full text

Caries-preventive effect of fissure sealants: a systematic review
Ingegerd MejaÁre, Peter LingstroÈm, Lars G. Petersson, Anna-Karin Holm, Svante
Twetman, Carina KaÈllestaÊl, Gunilla Nordenram, Folke LagerloÈf, Birgitta SoÈ der,
Anders Norlund, Susanna Axelsson and Helena Dahlgren
Department of Pediatric Dentistry, Eastman Dental Institute, Stockholm, Sweden; Faculty of
Odontology, Centre for Oral Sciences, MalmoÈ University, MalmoÈ , Sweden; Department of
Cariology, Faculty of Odontology, Sahlgrenska Academy at GoÈ teborg University, GoÈ teborg,
Sweden; Oral & Maxillofacial Unit, Central Hospital, Halmstad, Sweden; Departments of
Pedodontics and Odontology, Dental School, UmeaÊ University, UmeaÊ , Sweden; National
Institute of Public Health, Stockholm, Sweden; Departments of Geriatric Dentistry, Cariology
and Oral Dental Hygiene, Institute of Odontology, Karolinska Institute, Huddinge, Sweden; The
Swedish Council on Technology Assessment in Health Care, Stockholm, Sweden
MejaÁre I, LingstroÈ m P, Petersson LG, Holm A-K, Twetman S, KaÈ llestaÊl C, Nordenram G, LagerloÈf F,
SoÈder B, Norlund A, Axelsson S, Dahlgren H. Caries-preventive effect of fissure sealants: a systematic
review. Acta Odontol Scand 2003;61:321±330. Oslo. ISSN 0001-6357.
The objectives of this study were to evaluate systematically the evidence of the caries-preventive effect of
fissure sealing of occlusal tooth surfaces and to examine factors potentially modifying the effect. The search
strategies included electronic databases, reference lists of articles, and selected textbooks. Inclusion criteria
were randomized or quasi-randomized clinical trials or controlled clinical trials comparing fissure sealing
with no treatment or another preventive treatment in children up to 14 years of age at the start; the
outcome measure was caries increment; the diagnostic criteria had been described; and the follow-up time
was at least 2 years. Inclusion decisions were taken and grading of the studies was done independently by
two of the authors. The main measure of effect was relative risk reduction. Thirteen studies using resin-
based or glass ionomer sealant materials were included in the final analysis. The results showed that most
studies were performed during the 1970s and a single application had been utilized. The relative caries risk
reduction pooled estimate of resin-based sealants on permanent 1st molars was 33% (relative risk = 0.67;
CI = 0.55±0.83). The effect depended on retention of the sealant. In conclusion, the review suggests
limited evidence that fissure sealing of 1st permanent molars with resin-based materials has a caries-
preventive effect. The evidence is incomplete for permanent 2nd molars, premolars and primary molars
and for glass ionomer cements. Overall, there remains a need for further trials of high quality, particularly
in child populations with a low and a high caries risk, respectively. &Pit and fissure sealants; systematic review
Ingegerd MejaÁre, Eastman Dental Institute, Dalagatan 11, SE-113 24 Stockholm, Sweden. Tel. +46 8 729 8936, fax.
+46 8 310488, e-mail. ingegerd.mejare@ftv.sll.se
Fissure sealants have been widely used for more than three
decades in preventing caries, mainly in pits and fissures of
occlusal surfaces of premolars and molars. The method
was introduced in the late 1960s and involves the
application of a thin layer of resin directly on the fissures
after pretreatment with acid. The method is technique-
sensitive in that saliva contamination after the acid-etch
treatment destroys the tags created by the acid and thereby
the mechanical retention of the resin. The first generation
of resin-based sealants (no longer available) cured through
ultraviolet (UV) light. The second generation cured
automatically through chemical reactions, while the third
generation cures from visible light. The fourth generation
has fluoride incorporated in the resin.
In the middle of the 1970s, glass ionomer cement (GIC)
was introduced as an alternative to the resin-based sealants
(1). Retention to the tooth surface is based on the adhesive
properties of the cement, and the application of GIC is not
as sensitive to moisture as the resin-based sealants. Another
advantage with GIC is its release of fluoride. The cement
is relatively brittle, however, and a considerable disadvan-
tage with GIC as a fissure sealant is its insufficient
retention (2). In more recent years, resin-modified GICs
have been introduced onto the market.
Numerous clinical trials on the caries-preventive effect
of fissure sealing, mostly in permanent teeth and from the
1970s, have been reported. These studies have also been
the subject of several narrative reviews, i.e. (3±18) and a
meta-analysis (19). To our knowledge, no systematic
quantitative evaluation of the available evidence of the
caries-preventive effect of fissure sealing has yet been
published.
The objectives were to systematically determine the
effectiveness of fissure sealants in preventing caries of
occlusal surfaces of premolars and molars in the child/
adolescent population and to examine factors potentially
modifying the effect. The present review is one in a series
of systematic reviews of methods for caries prevention
performed by the Swedish Council on Technology
Assessment in Health Care (SBU), (20).
DOI 10.1080/00016350310007581 #2003 Taylor & Francis
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Material and methods
Search strategies for identification of studies
Relevant studies were identified by searching the
Medline and Cochrane Library databases (from 1966 to
November 2001 with a later update in August 2003). The
search was made with an information specialist at SBU.
The primary search strategy included the MeSH terms
`dental caries' and `pit and fissure sealants'. The term
`dental caries' was also combined with the words `sealant',
`sealants', and `sealing'. A total of 1250 records were
identified. Filters were then used to allow the inclusion of
only clinical trials, comparative studies, evaluation studies,
cohort studies, and retrospective studies. This search
resulted in 390 records.
Identification of relevant reports
All records electronically identified from the search
strategy listed above (390 records) were printed off and all
abstracts (or the article in full if an abstract was unclear or
missing) were assessed independently by 2 reviewers (2 of
the authors). Besides Swedish, Danish, Norwegian, and
English, articles in German, French, Italian, and Spanish
were considered. Letters, editorials and short communica-
tions were excluded. Obviously irrelevant reports (accord-
ing to study design/duration, participants or interventions)
were also discarded. An article was read in full if at least
one of the reviewers considered the study to be potentially
relevant according to the basic criteria for inclusion that
had been set up in advance: randomized (RCT) or quasi-
randomized (split mouth) studies or controlled clinical
trials (CCT), the outcome measure was caries increment
(DDFT/DDFS or Ddft/Ddfs) and the follow-up time at
least 2 years. All eligible studies retrieved from the
searches, review articles in English or German published
in 1980 or later, and one meta-analysis were scanned for
relevant references. Reference lists of relevant chapters
from preventive dentistry textbooks were consulted and
personal contacts were also used for retrieving relevant
articles. Another 13 articles were retrieved from the hand
search. The grey literature was not included.
A total of 113 studies were considered potentially
eligible from this search strategy. The two reviewers
further examined these studies in detail independently
using a previously prepared and pilot-tested data extrac-
tion form. The form included information about title,
authors, journal, year of publication, place of investigation,
type of sealant, application technique, study design (RCT,
quasi-randomized clinical trial or CCT), randomization
procedures, method of sampling, sample size, sample
characteristics such as baseline caries prevalence and
background exposure to fluoride sources, inclusion and
exclusion criteria, type of tooth/surface studied, diagnostic
criteria and reliability, independent outcome assessment,
attrition, follow-up time, measure(s) of effect, statistical
analyses, and sources of possible bias or confounders.
Attempts were made to contact authors in order to obtain
missing information or clarification when necessary. The
final inclusion criteria are given in Table 1.
When multiple reports of the same material had been
published, only the report with the longest follow-up time
was included. Studies comparing a resin-based sealant
material with a GIC sealant or xylitol chewing gum were
excluded, as were studies where participants were selected
on the basis of special general health conditions. Using
these criteria, 13 studies involving 3897 children/adoles-
cents were included in the final analysis. All potentially
eligible studies that were excluded, and the main reasons
for their exclusion, are given in Table 2.
Criteria for grading and evaluation
The two reviewers graded the 13 included studies
independently according to the criteria given in Table 3.
Any disagreement regarding inclusion/exclusion or grad-
ing was discussed and where necessary the study was
discussed in common with all the authors in order to
achieve consensus. The conclusions drawn from this
systematic review were based on a protocol proposed by
the SBU (21). The criteria for four levels of evidence are
given in Table 4.
Measures of treatment effect
The measures of treatment effect were relative risk
reduction (the number of decayed occlusal surfaces in the
controls minus the number of decayed surfaces in sealed
teeth divided by the number of decayed surfaces in the
controls) or prevented fraction (caries increment in the
controls minus caries increment in the sealed group
divided by caries increment in the controls). Since these
measures are independent of the caries incidence in the
population being studied, it was considered appropriate
also to calculate the net gain when possible. This measure
takes into account the caries incidence in the population
being studied and therefore provides a better estimate of
the magnitude of the likely benefit of the intervention. Net
gain (the number of decayed surfaces in the controls minus
the number of decayed surfaces in sealed teeth divided by
the number of sealed surfaces 100) was described in or
could be calculated from 10 of the 13 studies.
Table 1. Final inclusion criteria
.Outcome measure is caries increment (DDFT/DDFS or
Ddft/Ddfs)
.Randomized (grouping by children) or quasi-randomized (split
mouth) clinical trials or controlled clinical trials (including grouping
by school class)
.Teeth/groups of teeth under investigation speci®ed
.Diagnostic criteria de®ned
.Children or adolescents aged 14 at the start of the study (8
years for 1st permanent molars and 14 years for 2nd molars)
.Follow-up time at least 2 years
322 I. MejaÁre et al. ACTA ODONTOL SCAND 61 (2003)
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The pooled estimate of effect was calculated using the
Comprehensive Meta-analysis Program (Biostat, Inc. N.J.,
USA, version 1.0.23). In order to get as homogeneous a
material as possible, only studies using resin-based
materials and a single sealant application on 1st perma-
nent molars were included. Eight studies using the tooth
pair as the unit of analysis met these criteria. The caries-
preventive effect was expressed as relative risk (Fig. 1.)
Results
A total of 113 studies were assessed in detail. Thirteen of
these studies met the inclusion criteria (Table 1) and
formed the basis for the evaluation of evidence of the
caries-preventive effect of fissure sealants according to the
criteria given in Tables 3 and 4. The main characteristics
of the 13 studies are presented in Table 5. None of them
was graded as A (high value as evidence), 2 were graded as
Table 2. Excluded studies and the main reasons for exclusion. A
study can appear under more than one heading
Reason for exclusion Reference
Adults (35, 36)
Attrition rate cannot be calculated (37, 38
1
) (39, 40)
Caries-free subjects excluded (41)
Comparative study (42±48)
Compares high-risk and low-risk children (49)
Compares resin-based and GIC
2
sealants (2, 50±52) (53±57)
Compares resin-reinforced GIC with
conventional GIC (58)
Compares 2 resin-based materials (59, 60)
Compares xylitol chewing gum and
®ssure sealants (61)
Diagnostic criteria missing (62±65, 66
3
) (36, 67±70)
Few subjects, major bias (71, 72)
Follow-up (63, 73±84) (85±103)
Historic controls (90, 94, 97, 99, 101,
103, 104)
High attrition rate (64, 68, 81, 105, 106)
No intervention (63, 73, 78, 107, 108)
Prevention program (47, 83, 109±118)
Results reported twice (119)
Retrospective study (98, 117, 120)
Teeth not speci®ed (121)
Less than 24 months' observation (67, 121±124)
Underway results (125)
4
(126)
4
(127)
5
(128)
6
(129)
7
(130)
7
(131)
8
(132)
8
(133)
9
(134, 135
10
)
1
Only sticky fissures.
2
Glass ionomer cement.
3
Population not
defined.
4
Final data in (23).
5
Final data in (33).
6
Final data in (29).
7
Final data in (28).
8
Final data in (25).
9
Final data in (136).
10
Final
data in (32).
Table 3. Criteria for grading of studies
A (high value as evidence) B (moderate value as evidence) C (limited value as evidence)
All criteria stated below should be met All criteria stated below should be met One or more of the conditions stated below
Randomization by children Randomization by children, school class or
tooth pair (split mouth)
No or unclear randomization
Diagnostic reliability test made and described Diagnostic reliability test made and described Diagnostic reliability test not described
Baseline DFT/DFS (dft/dfs) values described Baseline DFT/DFS (dft/dfs) values described Baseline DFT/DFS (dft/dfs) values not
described
Independent outcome assessment Independent outcome assessment No independent outcome assessment
Statistical analysis (difference between test
and control group calculated)
Relative risk reduction or relative risk
described
Relative risk reduction or relative risk not
described and cannot be calculated from
the results
Attrition reported, explained, not exceeding
10%/year
Attrition reported, not explained but not
exceeding 10%/year
Attrition not reported or more than
10%/year
A representative sample of the population
under study; results can be generalized
The population under study de®ned; results
cannot be generalized
The population under study not de®ned
Bias and possible confounders have been
considered
Bias and possible confounders have been
considered
Potentially signi®cant bias/confounders that
could distort the results not considered
Fig. 1. The pooled estimate caries preventive effect of ®ssure sealing
expressed as relative risk. A meta-analysis including 8 studies using
resin-based materials and a single sealant application on occlusal
surfaces of permanent 1st molars. RR = relative risk, CI = 95%
con®dence interval, N = total number of teeth. Random model.
Table 4. Definition of evidence level (21)
.Strong evidence: At least 2 studies with high level of evidence (A) or
good systematic review
.Moderate evidence: One study with level (A) and at least 2 studies
with moderate level of evidence (B)
.Limited evidence: At least 2 studies with level (B)
.Incomplete evidence: Less than 2 studies with level (B)
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B (moderate value as evidence), and 11 as C (limited value
as evidence).
Relative risk reduction
The effect of fissure sealing with resin-based materials
on permanent 1st molars had been evaluated in 11 of the
13 studies. Using a single sealant application, the relative
risk reduction varied from 4% to 54% and for repeated
applications from 69% to 93% (Table 5). The pooled
estimate effect of resin-based fissure sealing of 1st perma-
nent molars showed that the relative risk of developing
caries in fissure-sealed teeth relative to untreated control
teeth was 0.67 (confidence intervals 0.55±0.83), corre-
sponding to a relative risk reduction of 33% (Fig. 1). The
assumption that the studies were taken from the same
population was rejected, since the test of heterogeneity was
highly significant (P< 0.001). The results were therefore
valued according to a conservative assumption that the
studies represented different populations (random effects
model). All but one of these studies (22) was graded as
being of limited value as evidence (C).
Evidence
Two studies were graded as a moderate level as
evidence (22, 23). Both have an observation time of 4
years and investigated the effect on permanent 1st molars.
The former used a chemically polymerizing sealant and
defective sealants were replaced. The relative risk reduc-
tion was 69%. The latter used a light-cured sealant and a
single application, resulting in a risk reduction of 22%.
Thus, the evidence that fissure sealing of permanent 1st
Table 5. Main characteristics of the 13 studies included
First author,
year (ref) Design
1
Intervention
2
No. of
subjects/pair
of teeth
3
(at start)
Age
(year) Tooth Application
Follow-up
(year)
Independent
assessment
Attrition
rate (%)
Treatment
effect
4
(%)
Value as
evidence
Bravo, 1997
(23)
CCT
5
Delton (CP) 104/365 (T) 6±8 1st molar Repeated 4 Yes 19 69 B
128/434 (C) Analysed
Leake, 1976
(22)
CCT
(SM)
Nuvaseal
(LC)
518/840 5±7 1st molar Single 4 Yes 19 22 B
Not explained
Charbeneau,
1979 (33)
CCT
(SM)
Kerr (CP) 143/229 5±8 1st molar Single 4 No 19 54 C
Not explained
Going, 1977
(29)
CCT
(SM)
Nuvaseal
(LC)
84/479 10±14 Molars Single 4 Yes 20 30 C
Premolars Not explained
Higson, 1976
(31)
CCT
(SM)
Nuvaseal
(LC)
50/90 6±8 1st molar Single 2 No 10 23 (NS) C
Explained
Horowitz,
1977 (28)
CCT
(SM)
Nuvaseal
(LC)
241/604 5±7 1st molar Single 5 Yes 44 30±38 C
12±13 2nd molar Explained
Premolars
Pereira, 2003
(25)
CCT
(Ch)
Vitremer
(RMGIC)
208/832 6±8 1st molar Single 3 Yes 18 56 C
Ketac Bond
(GIC)
Not explained
Poulsen, 1979
(32)
RCT
(Ch)
Concise
(CP)
256/1024 6 1st molar Single 2 No 27 12 (NS) C
Explained
Raadal, 1984
(30)
CCT
(SM)
Concise
(CP)
121/210 6±9 1st molar Single 2 Yes Not given 24 (NS) C
Richardson,
1980 (136)
CCT
(SM)
Concise
(CP)
266/425 7±8 1st molar Single 4 No 17 62 C
Not explained
Songpaisan,
1995 (24)
CCT
(Ch)
Delton
(CP)
133 (T) 12±13 2nd molar Repeated 2 Yes 11 93 C
143 (C) Explained
Fuji III
(GIC)
221 (T)
118 (C)
7±8 1st molar Repeated 2 Yes 14 52±74 C
Fuji III
(GIC)
261 (T)
143 (C)
12±13 2nd molar Repeated 2 Yes 11 20±31 (NS) C
Stephen,
1978 (27)
CCT
(Ch)
TP2006
(LC)
269 (T) 5±7 1st molar Single 4 No < 10 4 (NS) C
273 (C) Explained
Thylstrup,
1978 (26)
CCT
(SM)
Concise
(CP)
217/452 7 1st molar Single 2 Yes 12 50 C
Explained
1
CCT = controlled clinical trial, RCT = randomized clinical trial, SM = split mouth, Ch = grouped by children.
2
CP = chemically polymerized, LC = light cured, GIC = glass ionomer cement, RMGIC = resin-modified glass ionomer cement.
3
T = test, C = control.
4
Relative risk reduction (%), NS = no statistically significant difference in caries rate between the test and control groups.
5
Randomized on school class.
324 I. MejaÁre et al. ACTA ODONTOL SCAND 61 (2003)
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molars with resin-based materials has a caries-preventive
effect was rated as limited (level 3; Table 4).
One study used GIC for sealing permanent 1st and 2nd
molars (24). Using repeated applications, the prevented
fraction after 2 years of follow-up was significant for 1st
molars and amounted to 52±74%, depending on the
operator. Another study (25) used GIC or RMGIC and a
single sealant application. The relative risk reduction of
the two GIC materials compared with unsealed teeth was
56% after 3 years of follow-up. Both studies were con-
sidered to have a limited value as evidence (C). There was
thus incomplete evidence that fissure sealing with glass
ionomer cements has a caries-preventive effect (level 4;
Table 4).
Study characteristics
One study was randomly grouped by children and
classified as RCT, while the rest were classified as CCT.
For some studies, the randomization procedure was
unclear. They were all classified as CCT. The study by
Bravo et al. (23) was grouped by school-class and 8 studies
had used the split mouth design (Table 5). In all but one
study, teeth with sticky fissures were considered eligible for
sealing. The reliability test at the start and/or the inde-
pendent assessment at the end of the study were clearly
described in half of the studies.
A number of measures of evaluation were used: relative
risk reduction (22, 25±29), prevented fraction of the mean
DFS increment (24), survival analysis and relative risk (23),
and net gain (29, 30). The whole occlusal surface was used
as the basis for calculating the effect in 11 studies, while 2
used part of the fissure system for this purpose. A statistical
analysis of the difference in caries increment between
sealed and non-sealed teeth was made in about half of the
studies (23±27, 31, 32) and confidence intervals were
described in three (23, 26, 29).
Most studies were published in the 1970s. The follow-up
time varied from 2 to 5 years. The majority investigated
the effect on permanent 1st molars and used a single
sealant application, while regular repeated applications
were done in two studies. Five studies used UV-light-cured
sealants, 7 chemically polymerized sealants, while one used
both chemically polymerized and GIC sealants. One study
used a conventional GIC and a RMGIC (resin-modified
GIC) (Table 5).
Influence of retention of the sealant
Four studies described the association between retention
of the sealant and the caries-preventive effect. The close
relationship between the two factors is illustrated in Fig. 2.
Effect on different tooth surfaces and net gain
The upper 1st permanent molar showed less relative risk
reduction compared with the lower molar (Table 6). Three
studies investigated the effect on the 2nd permanent
molar: one used repeated applications and reported a
prevented fraction of 93% (24), while the other two used a
single application and found a relative risk reduction of
about 30% (28, 29). The materials, however, are small in
the two latter studies. All three studies were graded as C
(limited value as evidence). There was thus incomplete
evidence that fissure sealing of permanent 2nd molars has
any caries-preventive effect. The net gain from fissure
sealing in the present review varied from zero to 42 (Table
7).
Studies that met the inclusion criteria regarding the
caries-preventive effect of visible light-cured or fluoride-
containing resin-based sealants could not be identified.
The same applied to the use of sealants on premolars and
primary molars.
Fig. 2. Relative caries risk reduction related to retention of the
sealant. Results from four studies reporting on this matter. Adenotes
intact sealant, &denotes lost sealant.
Table 6. Relative caries risk reduction of upper and lower occlusal surfaces of permanent 1st molars. Data from 3 studies using a single sealant
application
First author
No. of participants/
no. of tooth pairs
Follow-up time
(years)
Relative risk reduction
Upper Lower Total
Charbeneau (33) 143/229 4 53 55 54
Higson (31) 50/90 2 12 35 23
Horowitz (28) 43/43 5 73630
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Discussion
The inclusion criteria in the present systematic review are
much stricter than those used in the meta-analysis by
Llodra (19), where 24 studies were included and an overall
relative caries risk reduction of 71% was suggested. This is
much higher than the finding of a pooled relative risk
reduction estimate of 33% in the present meta-analysis. It
should be noted, though, that Llodra found a significantly
lower relative risk reduction (59%) after 4 years of follow-
up. It should also be pointed out that the aggregated data
in our meta-analysis derived from studies thatÐwith one
exceptionÐwere graded as a limited level of evidence (C),
and the pooled estimate effect must be interpreted with
this in mind.
Most clinical trials on the caries-preventive effect of
fissure sealants have used the split mouth design, whereby
the caries-preventive effect can be assessed by comparing
teeth with sealants with untreated control teeth with the
individual as its own control. The split mouth design is
useful for assessing the efficacy of fissure sealants. How-
ever, for evaluating the effect from a population perspec-
tive (effectiveness), the split mouth design has certain
disadvantages. Thus, since the inclusion criterion is a child
with at least one pair of caries-free molars, a caries-active
child will be excluded. In other words, not all children
have the same chance to participate. The split mouth
design can therefore be regarded as a quasi-randomized
study. Furthermore, the longer the time after eruption the
greater the risk that the caries-active child will be excluded
from the study (26, 27). This type of error can be reduced
if the study starts soon after eruption of the teeth to be
investigated. Even though the inclusion criteria for this
review were restricted to studies starting within 2 years
after eruption of the tooth to be investigated, selection bias
could not be ruled out. There is thus an obvious risk that
caries-active children were excluded when they could not
present with at least one pair of caries-free molars. The
proportion of excluded children is given in 9 of the 13
studies and in 5 it was at least 20% (22, 24, 27, 28, 33).
None of these studies reported the dft (dfs)/DFT (DFS)
values of these children, and it is therefore not possible to
assess to what extent they differed from those eligible for
the study.
There are a number of factors potentially modifying the
caries-preventive effect of fissure sealing, such as caries
prevalence in the population under study, single or
repeated sealant applications, type of sealant material,
follow-up time, type of tooth and jaw (upper or lower), the
operator and the content of fluoride in the drinking water
(19). Owing to the small number of studies and their
heterogeneity in study populations and design, no meta-
regression analysis stratified by these factors was per-
formed because of its very limited power to detect any true
relationship between the preventive effect and the specified
factors. The large variety of measures of evaluation and
the differing units of analysis also complicate comparisons.
However, some possible modifying factors are discussed.
The majority of the studies were from the 1970s, when
caries prevalence in general was much higher than it is
today in many Western countries. It can therefore be
questioned to what extent the populations studied are
representative of today's child populations. Two studies
investigated the effect of fissure sealing in children with a
low caries prevalence (30, 32). Both reported fairly low
relative risk reductions of 12% and 24%, respectively, and
with no statistically significant difference between sealant
and control groups. Unfortunately, both studies suffer
from methodological shortcomings and they were there-
fore graded as of limited value as evidence. It is note-
worthy that no RCT or CCT could be identified where
children at high risk of caries had been investigated.
It might be argued that studies using outdated and
perhaps inferior sealant materials should not be included
in a systematic review. However, without them we would
have lost important information about the principle effects
of fissure sealing and the number of included studies would
have been small. Furthermore, because of the limited
number of studies and several interacting factors it is not
possible to draw inferences from the present review about
whether or not the material itself played a decisive role.
However, the retention influenced the relative risk reduc-
tion, as illustrated in Fig. 2. Replacement of defective
sealants therefore seems to be a strong modifying factor, as
illustrated also by the relatively high-risk reductions of
69% and 93%, respectively, in the two studies where this
strategy had been used (23, 24).
Another modifying factor could be the type of tooth.
The materials are small and any interference is therefore
uncertain, but the results indicate a less good effect on
upper 1st molars compared with lower 1st molars (Table
6).
Little attention has been paid to the long-term effect of
fissure sealants, and the longest follow-up time in the
present review was 5 years (28). The effect of follow-up
Table 7. The net gain (= number of decayed control teeth minus
number of decayed sealed teeth divided by total number of sealed
teeth 100) of a single sealant application. Results from 10 studies
First author
Follow-up
time (years)
Type of
tooth Net gain*
Charbeneau (33) 4 1st molars 42
Going (29) 4 2nd molars, 12/43**
Premolars 23
Higson (31) 2 1st molars 12
Horowitz (28) 5 1st molars 10
Premolars 9
2nd molars 14
Leake (22) 4 1st molars 15
Raadal (30) 2 1st molars 7
Richardson (136) 4 1st molars 34
Stephen (27) 4 1st molars 0
Thylstrup (26) 2 1st molars 32
Pereira (25) 3 1st molars 18
* No. of teeth saved per 100 sealed teeth; **upper molars = 12; lower
molars = 43.
326 I. MejaÁre et al. ACTA ODONTOL SCAND 61 (2003)
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time on the caries-preventive effect of sealant could not be
evaluated in the present review due to too few studies.
Llodra (19), however, concluded that the effect decreased
as follow-up time increased. Bitewing radiography at the
end of the study was not used in any of the studies. The
extent to which dentin caries is present under sealed
occlusal surfaces, in general, is unknown. It is noteworthy,
though, that radiographic evidence of dentin caries was
found in 50% of fissure-sealed molars in 17-year-olds (34).
More than half of the studies in which net gain could be
calculated had a value of less than 20 (Table 7). The level
of a reasonable net gain is arbitrary, but it can be
questioned whether a net gain under 20 justifies fissure
sealing from a cost-benefit point of view.
Implications for research
Despite the large number of clinical trials evaluating the
caries-preventive effect of fissure sealants, there is a great
need for well-designed randomized trials, particularly in
child populations with a low and a high caries risk,
respectively. The long-term effects of fissure sealing are
also important to evaluate. It is important that future trials
include the benefit and cost-effectiveness of fissure sealing.
In conclusion, this review suggests limited evidence that
resin-based fissure sealing of 1st permanent molars has a
caries-preventive effect. There is incomplete evidence that
fissure sealing of primary molars, premolars, and perma-
nent 2nd molars has a caries-preventive effect, or that
fissure sealing is beneficial in child/adolescent populations
at low-risk for caries, and the same applies to populations
at high risk for caries. Furthermore, there is incomplete
evidence that fissure sealing with glass ionomer cements
has a caries-preventive effect.
Acknowledgement.ÐWe express our gratitude to Associate Professor in
Health Services Research Bengt Brorsson at SBU for skillful
assistance with the meta-analysis.
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Accepted 14 October 2003
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