CRITICAL APPRAISAL
Evidence for Sealing versus Restoration of Early Caries Lesions Author ANDREA FERREIRA ZANDONA, DDS, MSD, PhD* Associate Editor EDWARD J. SWIFT, JR., DMD, MS
Resin-based pit and fissure sealants are established tools for prevention of dental caries. Conversely, the role of sealants for management of existing early dental caries lesions has been disputed despite the recommendation from the American Dental Association Council on Scientific Affairs.The development of more sensitive caries detection technologies has revealed that many sealants have likely been placed over incipient lesions inadvertently over the years. However, the issue remains whether sealing overt incipient occlusal caries lesions leads to a worse outcome versus restoring the surface. Certainly, there are diverse opinions regarding this topic. But what does the science say? This Critical Appraisal presents evidence from several clinical trials for sealing incipient occlusal caries lesions.
Sealing Occlusal Caries Lesions in Adults Referred for Restorative Treatment: 2–3 Years of Follow-Up A. BAKHSHANDEH, V. QVIST, K.R. EKSTRAND Clinical Oral Investigations 2012 (16:521–9)
ABSTRACT Objective: The aim of this study was to assess the possibility of arresting occlusal caries lesions in adults by sealant as well as to assess the presence of radiographic progression, arrest, and regression of the sealed lesions. Materials and Methods: Seventy-two occlusal caries lesions in 52 adult patients referred for restorative treatment by senior lecturers at School of Dentistry, Copenhagen, Denmark were included. When a patient had more than one occlusal caries lesion, randomization between sealing and restoration was made; otherwise, the lesion was sealed. In total, 60 resin sealants and 12 composite restorations were made. The
follow-up period was 25–38 months (mean = 33 months). Data were analyzed using non-parametric statistics including kappa statistics. Results: After 2–3 years, the dropout rate was 15%; two patients did not show up for control and nine previously sealed lesions were restored by the patients’ general practitioners. All 12 restorations and 39 of the remaining 49 sealants were well functioning. Seven (14%) sealants were repaired or replaced due to failure, and three (6%) sealed lesions were restored due to caries progression (p > 0.05). The radiographic assessment showed caries progression beneath five (10%) sealants, caries regression beneath one (2%) sealant, and unchanged depth beneath 43 (88%) sealants and all restorations (p > 0.05).
*Associate Professor, Department of Operative Dentistry, University of North Carolina at Chapel Hill School of Dentistry, Chapel Hill, NC, USA
© 2015 Wiley Periodicals, Inc.
DOI 10.1111/jerd.12144
Journal of Esthetic and Restorative Dentistry
Vol 27 • No 1 • 55–58 • 2015
55
CRITICAL APPRAISAL Andrea et al.
Conclusions: The majority of the referred lesions were successfully arrested by sealants, indicating the possibility for extending the criteria for sealing occlusal caries lesions in adults. However, a longer observation period is needed for final conclusions. Extending the criteria of therapeutic sealing of occlusal caries lesions in adults could lead to increased dental health.
COMMENTARY The lesions included in this study ranged from enamel lesions to cavitated lesions in the middle third of the dentin. Most lesions were in the outer third of dentin per radiographic examination. The authors do not present data to indicate if the failure rate (or lesion
progression beneath the sealants) was an occurrence associated or not with the initial lesion depth, which limits the data interpretation. The sealants were placed under optimal conditions (rubber dam isolation), which clearly improved the sealant retention rate. Still, despite a large number of cavitated lesions in the middle third of dentin, caries progression underneath sealed lesions was a rare occurrence at only 10%. Considering that restoration was avoided in 88% of the surfaces, placing sealants on early lesions should be considered a viable option on compliant patients for whom sealant retention can be monitored. Although the authors’ sealing of occlusal caries was probably beyond what most clinicians would feel comfortable, this study confirms that in a well sealed surface a lesion can be arrested.
Arrest of Non-Cavitated Dentinal Occlusal Caries by Sealing Pits and Fissures: A 36-Month, Randomized Controlled Clinical Trial B.C. BORGES, J. DE SOUZA BORGES, R. BRAZ, M.A. MONTES, I.V. DE ASSUNÇÃO PINHEIRO International Dental Journal 2012 (62:251–5)
ABSTRACT Objective: This study aimed to evaluate the progression of sealed non-cavitated dentinal occlusal caries in a randomized controlled clinical trial. Materials and Methods: Sixty teeth with non-cavitated dentinal occlusal caries were selected in patients with a high risk for caries. Patients were randomly divided into two groups so that each group included 30 teeth. Patients in the experimental group were given oral hygiene instructions and a fissure sealant. Patients in the control group were given oral hygiene instructions only. Caries progression and sealant loss were monitored over a period of 36 months by clinical and radiographic examination. Results: Clinical and radiographic progression of caries was significantly more frequent in the control group than in the experiment group. Sealants were lost in three teeth, resulting in caries progression, but this was
56
Vol 27 • No 1 • 55–58 • 2015
Journal of Esthetic and Restorative Dentistry
apparent only at the 12-month follow-up. At the 24and 36-month recall appointments, neither sealant loss nor caries progression was observed. Conclusion: The pit and fissure sealant used in this study was shown to be effective in arresting carious lesions at 36 months.
COMMENTARY In this study, the lesions extended from the dentinonenamel junction to the middle third of dentin, with no clinical cavitation present. The population was a high caries risk population, ranging in age from preteens to young adults (10–22 years old). There are some limitations to this study: it compared the use of a sealant to doing nothing (wait and watch approach), although oral hygiene instructions were provided to both groups. It must be noted that the treatment was delivered under optimal conditions (using a rubber dam). The statistical analyses is a weakness of this study as there was the lack of a power calculation, and the
DOI 10.1111/jerd.12144
© 2015 Wiley Periodicals, Inc.
CRITICAL APPRAISAL Andrea et al.
authors assumed each tooth to be an independent analysis unit. Unfortunately, the authors do not provide information regarding the depth of the lesions that progressed; thus, no assumptions can be made regarding the effect of lesion depth on lesion progression. Nevertheless, caries progression was observed in three (11.5%) of the 26 sealed surfaces—but
only when there was incomplete sealant retention. The study supports the concept that a lesion can be arrested beneath a well-sealed surface. The authors mention how sealants can avoid or at least delay placing teeth in the restorative cycle. This study also suggests that the wait and watch approach will likely lead to lesion progression.
Clinical Evaluation of Sealants and Preventive Resin Restorations in a Group of Environmentally Homogeneous Children P.C. LEKIC, D. DENG, D. BROTHWELL Journal of Dentistry for Children 2006 (73:15–19)
ABSTRACT Objective: Pit and fissure sealants reduce occlusal caries when proper patient selection and application techniques are followed. To increase retention rate of sealants over time, good adaptation and deep sealant penetration are important. Studies remain inconclusive, however, as whether bur preparation of pits and fissures would increase the adaptation and penetration thus improving sealant retention. The aim of this study was to assess if tooth preparation prior to sealant application improves sealant retention. Methods: In this prospective cohort study, 43 children and adolescents from four Hutterite colonies were, for three years, bussed to the University of Manitoba pediatric dental clinic, Winnipeg, Manitoba, Canada, for comprehensive dental care including sealant placement using standard procedures. These came from a community with homogeneous socioeconomic status, dietary habits, fluoride intake, and lifestyles. The decision of tooth preparation prior to sealant application was made ad hoc. Of 122 treated permanent posterior teeth, 54 were treated as preventive resin restorations (PRRs, type A—minimal fissure preparation using #¼ or ½ round bur or type B—caries removal with #1 or 2 round bur) and 68 were non-prepared sealants.
© 2015 Wiley Periodicals, Inc.
DOI 10.1111/jerd.12144
Results: After one year, teeth prepared for type B PRRs and restored with flowable composite resins had significantly lower retention rates (27% versus 63%) than teeth with non-prepared sealants or type A PRRs. Teeth prepared for type B PRRs were also significantly more likely to have caries on follow-up examination (50% versus 11%) than were teeth with non-prepared sealants or type A PRRs. Conclusion: These results suggest that type B preventive resin restorations restored with flowable composites are not helpful in terms of retention or caries reduction.
COMMENTARY This study does not provide information regarding the surface status at placement of sealants or flowable composites. It can be assumed that type A or type B were placed for surfaces that had an initial lesion, but no assumptions can be made for surfaces that were sealed only (with no preparation). Only clinical evaluation was performed both at baseline and at follow-up, limiting information regarding lesion progression. Despite placement of sealants by dental students, and isolation with a rubber dam not being consistent, there was complete sealant loss in 22% of the teeth, but only 9% of the teeth had caries at follow-up. There was no caries in teeth that had partial
Journal of Esthetic and Restorative Dentistry
Vol 27 • No 1 • 55–58 • 2015
57
CRITICAL APPRAISAL Andrea et al.
sealants, so only complete sealant loss seemed to increase the risk for caries. On the other hand, restorations with flowable composites in this study were more likely to fail and had more caries lesions at follow-up.
McComb D. Systematic review of conservative operative caries management strategies. J Dent Educ 2001;65:1154–61.
SUGGESTED READING
O’Donnell JA, Modesto A, Oakley M, et al. Sealants and dental caries Insight into dentists’ behaviors regarding implementation of clinical practice recommendations. J Am Dent Assoc 2013;144:e24–30.
Ahovuo-Saloranta A, Hiiri A, Nordblad A, et al. Pit and fissure sealants for preventing dental decay in the permanent teeth of children and adolescents. Cochrane Database Syst Rev 2009;(4):CD001830. Dennison JB, Hamilton JC. Treatment decisions and conservation of tooth structure. Dent Clin North Am 2005;49:825–45. Houpt M, Fukus A, Eidelman E. The preventive resin (composite resin/sealant) restoration: nine-year results. Quintessence Int 1994;3:155–9.
Mertz-Fairhurst EJ, Curtis JW Jr, Ergle JW, et al. Ultraconservative and cariostatic sealed restorations: results at year 10. J Am Dent Assoc 1998;129: 69–77.
Qvist V. Longevity of restorations: the “death spiral.” In: Fejerskov O, Kidd E, editors. Dental caries. The disease and its clinical management, 2nd ed. Oxford: Blackwell; 2008, pp. 443–56. Tellez M, Gray SL, Gray S, et al. Sealants and dental caries: dentists’ perspectives on evidence-based recommendations. J Am Dent Assoc 2011;142: 1033–40.
THE BOTTOM LINE • There is much concern that placement of sealants over early dental caries can lead to further progression of caries lesions. • The results of controlled clinical trials provide evidence that lesion does not progress if the surface is sealed well. • Conditions are relatively ideal in some clinical studies, so “daily practice” results might be different from those obtained under such relatively ideal conditions. However, in at least one study included here, conditions were less than ideal and the failure rate was similar. • The clinical trials show that sealant retention is an important factor to determine success. • The studies indicate that progression is more likely if a sealant is partially retained, but not all lesions will progress underneath a partially retained sealant. • However, there is no evidence that lesion will progress faster underneath a sealant than in an unsealed surface. Therefore, placing a sealant will at best hamper lesion progression and at worst delay placement of a tooth into the restorative cycle.
58
Vol 27 • No 1 • 55–58 • 2015
Journal of Esthetic and Restorative Dentistry
DOI 10.1111/jerd.12144
© 2015 Wiley Periodicals, Inc.
Evidence for Sealing versus Restoration of Early Caries Lesions Author ANDREA FERREIRA ZANDONA, DDS, MSD, PhD* Associate Editor EDWARD J. SWIFT, JR., DMD, MS
Resin-based pit and fissure sealants are established tools for prevention of dental caries. Conversely, the role of sealants for management of existing early dental caries lesions has been disputed despite the recommendation from the American Dental Association Council on Scientific Affairs.The development of more sensitive caries detection technologies has revealed that many sealants have likely been placed over incipient lesions inadvertently over the years. However, the issue remains whether sealing overt incipient occlusal caries lesions leads to a worse outcome versus restoring the surface. Certainly, there are diverse opinions regarding this topic. But what does the science say? This Critical Appraisal presents evidence from several clinical trials for sealing incipient occlusal caries lesions.
Sealing Occlusal Caries Lesions in Adults Referred for Restorative Treatment: 2–3 Years of Follow-Up A. BAKHSHANDEH, V. QVIST, K.R. EKSTRAND Clinical Oral Investigations 2012 (16:521–9)
ABSTRACT Objective: The aim of this study was to assess the possibility of arresting occlusal caries lesions in adults by sealant as well as to assess the presence of radiographic progression, arrest, and regression of the sealed lesions. Materials and Methods: Seventy-two occlusal caries lesions in 52 adult patients referred for restorative treatment by senior lecturers at School of Dentistry, Copenhagen, Denmark were included. When a patient had more than one occlusal caries lesion, randomization between sealing and restoration was made; otherwise, the lesion was sealed. In total, 60 resin sealants and 12 composite restorations were made. The
follow-up period was 25–38 months (mean = 33 months). Data were analyzed using non-parametric statistics including kappa statistics. Results: After 2–3 years, the dropout rate was 15%; two patients did not show up for control and nine previously sealed lesions were restored by the patients’ general practitioners. All 12 restorations and 39 of the remaining 49 sealants were well functioning. Seven (14%) sealants were repaired or replaced due to failure, and three (6%) sealed lesions were restored due to caries progression (p > 0.05). The radiographic assessment showed caries progression beneath five (10%) sealants, caries regression beneath one (2%) sealant, and unchanged depth beneath 43 (88%) sealants and all restorations (p > 0.05).
*Associate Professor, Department of Operative Dentistry, University of North Carolina at Chapel Hill School of Dentistry, Chapel Hill, NC, USA
© 2015 Wiley Periodicals, Inc.
DOI 10.1111/jerd.12144
Journal of Esthetic and Restorative Dentistry
Vol 27 • No 1 • 55–58 • 2015
55
CRITICAL APPRAISAL Andrea et al.
Conclusions: The majority of the referred lesions were successfully arrested by sealants, indicating the possibility for extending the criteria for sealing occlusal caries lesions in adults. However, a longer observation period is needed for final conclusions. Extending the criteria of therapeutic sealing of occlusal caries lesions in adults could lead to increased dental health.
COMMENTARY The lesions included in this study ranged from enamel lesions to cavitated lesions in the middle third of the dentin. Most lesions were in the outer third of dentin per radiographic examination. The authors do not present data to indicate if the failure rate (or lesion
progression beneath the sealants) was an occurrence associated or not with the initial lesion depth, which limits the data interpretation. The sealants were placed under optimal conditions (rubber dam isolation), which clearly improved the sealant retention rate. Still, despite a large number of cavitated lesions in the middle third of dentin, caries progression underneath sealed lesions was a rare occurrence at only 10%. Considering that restoration was avoided in 88% of the surfaces, placing sealants on early lesions should be considered a viable option on compliant patients for whom sealant retention can be monitored. Although the authors’ sealing of occlusal caries was probably beyond what most clinicians would feel comfortable, this study confirms that in a well sealed surface a lesion can be arrested.
Arrest of Non-Cavitated Dentinal Occlusal Caries by Sealing Pits and Fissures: A 36-Month, Randomized Controlled Clinical Trial B.C. BORGES, J. DE SOUZA BORGES, R. BRAZ, M.A. MONTES, I.V. DE ASSUNÇÃO PINHEIRO International Dental Journal 2012 (62:251–5)
ABSTRACT Objective: This study aimed to evaluate the progression of sealed non-cavitated dentinal occlusal caries in a randomized controlled clinical trial. Materials and Methods: Sixty teeth with non-cavitated dentinal occlusal caries were selected in patients with a high risk for caries. Patients were randomly divided into two groups so that each group included 30 teeth. Patients in the experimental group were given oral hygiene instructions and a fissure sealant. Patients in the control group were given oral hygiene instructions only. Caries progression and sealant loss were monitored over a period of 36 months by clinical and radiographic examination. Results: Clinical and radiographic progression of caries was significantly more frequent in the control group than in the experiment group. Sealants were lost in three teeth, resulting in caries progression, but this was
56
Vol 27 • No 1 • 55–58 • 2015
Journal of Esthetic and Restorative Dentistry
apparent only at the 12-month follow-up. At the 24and 36-month recall appointments, neither sealant loss nor caries progression was observed. Conclusion: The pit and fissure sealant used in this study was shown to be effective in arresting carious lesions at 36 months.
COMMENTARY In this study, the lesions extended from the dentinonenamel junction to the middle third of dentin, with no clinical cavitation present. The population was a high caries risk population, ranging in age from preteens to young adults (10–22 years old). There are some limitations to this study: it compared the use of a sealant to doing nothing (wait and watch approach), although oral hygiene instructions were provided to both groups. It must be noted that the treatment was delivered under optimal conditions (using a rubber dam). The statistical analyses is a weakness of this study as there was the lack of a power calculation, and the
DOI 10.1111/jerd.12144
© 2015 Wiley Periodicals, Inc.
CRITICAL APPRAISAL Andrea et al.
authors assumed each tooth to be an independent analysis unit. Unfortunately, the authors do not provide information regarding the depth of the lesions that progressed; thus, no assumptions can be made regarding the effect of lesion depth on lesion progression. Nevertheless, caries progression was observed in three (11.5%) of the 26 sealed surfaces—but
only when there was incomplete sealant retention. The study supports the concept that a lesion can be arrested beneath a well-sealed surface. The authors mention how sealants can avoid or at least delay placing teeth in the restorative cycle. This study also suggests that the wait and watch approach will likely lead to lesion progression.
Clinical Evaluation of Sealants and Preventive Resin Restorations in a Group of Environmentally Homogeneous Children P.C. LEKIC, D. DENG, D. BROTHWELL Journal of Dentistry for Children 2006 (73:15–19)
ABSTRACT Objective: Pit and fissure sealants reduce occlusal caries when proper patient selection and application techniques are followed. To increase retention rate of sealants over time, good adaptation and deep sealant penetration are important. Studies remain inconclusive, however, as whether bur preparation of pits and fissures would increase the adaptation and penetration thus improving sealant retention. The aim of this study was to assess if tooth preparation prior to sealant application improves sealant retention. Methods: In this prospective cohort study, 43 children and adolescents from four Hutterite colonies were, for three years, bussed to the University of Manitoba pediatric dental clinic, Winnipeg, Manitoba, Canada, for comprehensive dental care including sealant placement using standard procedures. These came from a community with homogeneous socioeconomic status, dietary habits, fluoride intake, and lifestyles. The decision of tooth preparation prior to sealant application was made ad hoc. Of 122 treated permanent posterior teeth, 54 were treated as preventive resin restorations (PRRs, type A—minimal fissure preparation using #¼ or ½ round bur or type B—caries removal with #1 or 2 round bur) and 68 were non-prepared sealants.
© 2015 Wiley Periodicals, Inc.
DOI 10.1111/jerd.12144
Results: After one year, teeth prepared for type B PRRs and restored with flowable composite resins had significantly lower retention rates (27% versus 63%) than teeth with non-prepared sealants or type A PRRs. Teeth prepared for type B PRRs were also significantly more likely to have caries on follow-up examination (50% versus 11%) than were teeth with non-prepared sealants or type A PRRs. Conclusion: These results suggest that type B preventive resin restorations restored with flowable composites are not helpful in terms of retention or caries reduction.
COMMENTARY This study does not provide information regarding the surface status at placement of sealants or flowable composites. It can be assumed that type A or type B were placed for surfaces that had an initial lesion, but no assumptions can be made for surfaces that were sealed only (with no preparation). Only clinical evaluation was performed both at baseline and at follow-up, limiting information regarding lesion progression. Despite placement of sealants by dental students, and isolation with a rubber dam not being consistent, there was complete sealant loss in 22% of the teeth, but only 9% of the teeth had caries at follow-up. There was no caries in teeth that had partial
Journal of Esthetic and Restorative Dentistry
Vol 27 • No 1 • 55–58 • 2015
57
CRITICAL APPRAISAL Andrea et al.
sealants, so only complete sealant loss seemed to increase the risk for caries. On the other hand, restorations with flowable composites in this study were more likely to fail and had more caries lesions at follow-up.
McComb D. Systematic review of conservative operative caries management strategies. J Dent Educ 2001;65:1154–61.
SUGGESTED READING
O’Donnell JA, Modesto A, Oakley M, et al. Sealants and dental caries Insight into dentists’ behaviors regarding implementation of clinical practice recommendations. J Am Dent Assoc 2013;144:e24–30.
Ahovuo-Saloranta A, Hiiri A, Nordblad A, et al. Pit and fissure sealants for preventing dental decay in the permanent teeth of children and adolescents. Cochrane Database Syst Rev 2009;(4):CD001830. Dennison JB, Hamilton JC. Treatment decisions and conservation of tooth structure. Dent Clin North Am 2005;49:825–45. Houpt M, Fukus A, Eidelman E. The preventive resin (composite resin/sealant) restoration: nine-year results. Quintessence Int 1994;3:155–9.
Mertz-Fairhurst EJ, Curtis JW Jr, Ergle JW, et al. Ultraconservative and cariostatic sealed restorations: results at year 10. J Am Dent Assoc 1998;129: 69–77.
Qvist V. Longevity of restorations: the “death spiral.” In: Fejerskov O, Kidd E, editors. Dental caries. The disease and its clinical management, 2nd ed. Oxford: Blackwell; 2008, pp. 443–56. Tellez M, Gray SL, Gray S, et al. Sealants and dental caries: dentists’ perspectives on evidence-based recommendations. J Am Dent Assoc 2011;142: 1033–40.
THE BOTTOM LINE • There is much concern that placement of sealants over early dental caries can lead to further progression of caries lesions. • The results of controlled clinical trials provide evidence that lesion does not progress if the surface is sealed well. • Conditions are relatively ideal in some clinical studies, so “daily practice” results might be different from those obtained under such relatively ideal conditions. However, in at least one study included here, conditions were less than ideal and the failure rate was similar. • The clinical trials show that sealant retention is an important factor to determine success. • The studies indicate that progression is more likely if a sealant is partially retained, but not all lesions will progress underneath a partially retained sealant. • However, there is no evidence that lesion will progress faster underneath a sealant than in an unsealed surface. Therefore, placing a sealant will at best hamper lesion progression and at worst delay placement of a tooth into the restorative cycle.
58
Vol 27 • No 1 • 55–58 • 2015
Journal of Esthetic and Restorative Dentistry
DOI 10.1111/jerd.12144
© 2015 Wiley Periodicals, Inc.
