Comparison of Caries Prevention With Glass Ionomer and Composite Resin Fissure Sealants

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1 ORIGINAL ARTICLE Comparison of Caries Prevention With Glass Ionomer and Composite Resin Fissure Sealants Aylin Akbay Oba, 1 Türksel Dülgergil, 2 Işıl Şaroğlu Sönmez, 1 * Salih Doğan 3 Background/Purpose: Atraumatic restorative treatment (ART) was developed primarily for use in underserved areas of the world. This study was designed to compare caries prevention with high-viscosity glass ionomer cement (GIC) sealants placed according to the ART procedure and light-cured composite resin sealants after 3 years. Methods: The study was conducted in a boarding school in the city of Kırıkkale. Four experienced dentists placed a total of 207 sealants (91 GIC and 116 composite resin), without chair-side assistance, on the school premises. Results: A total of 137 sealants were available after 3 years. 55.3% of the GIC and 93.8% of the composite resin sealants were lost completely, and the difference between the two groups was statistically significant. Only six of 56 teeth in the GIC group and eight of 81 in the composite resin group showed caries. Conclusion: Under field conditions in which moisture control was not effective, a high-viscosity and less technique-sensitive glass ionomer material can be used as an effective sealant material, rather than resin. [J Formos Med Assoc 2009;108(11): ] Key Words: atraumatic restorative treatment, composite resins, dental caries, fissure sealants, glass ionomer cement The decline in caries over the past few decades has been associated mostly with the widespread use of fluoride. 1 Caries in children is seen predominantly in occlusal pits and fissures, and these surfaces of permanent teeth are particularly at risk. For example, in the United States, occlusal surface caries comprised 56% of the permanent tooth caries in 5 17-year-old children. 2 To overcome this problem, sealants have been developed and used successfully to prevent the most prevalent pit and fissure caries in children and adolescents. 3 However, such preventive programs are slow to reach the populations where they are needed most. Even if the cost of many preventive programs is low, only rarely do they reach the list of funding priorities in developing countries. Therefore, alternative, low-cost and effective ways to prevent dental diseases have been given priority. Of the many attempts carried out in rural districts, atraumatic restorative treatment (ART) is the most impressive. ART was developed in mid 1980s, and introduced some years later in a clinical setting in Malawi. 4 It was developed primarily for treating people living in underserved areas of the world where resources and facilities such as electricity and trained manpower are limited. 5,6 Since its introduction, ART also has been considered as a preventive measure, with the sealing of occlusal 2009 Elsevier & Formosan Medical Association Department of Pediatric Dentistry, 2 Department of Operative Dentistry, School of Dentistry, University of Kırıkkale, and 3 Department of Pediatric Dentistry, School of Dentistry, University of Ankara, Turkey. Received: January 19, 2008 Revised: March 17, 2009 Accepted: April 9, 2009 *Correspondence to: Dr Işıl Şaroğlu Sönmez, Kırıkkale Üniversitesi, Diş Hekimliği Fakültesi, Pedodonti ABD, Kırıkkale, Turkey. isilsaroglu@yahoo.com 844 J Formos Med Assoc 2009 Vol 108 No 11

2 Glass ionomer and resin fissure sealants surfaces with glass ionomer material. A low-filled glass ionomer was used in all the cited sealant studies. However, high-filled glass ionomers have been produced in recent years. The 3-year retention rates of partially and fully retained sealants using high-filled glass ionomers have been reported to be 71 72%. 7,8 These rates are higher than those for low-filled glass ionomers Highfilled sealants have been placed, as part of the ART approach, in the first and second molars of adolescents. Generally, it is accepted that resin-based sealant materials are retained longer. 3 However, glass ionomer cement (GIC) is not as sensitive to moisture as the resin-based sealants. This issue is still problematic, and only a few data are available to compare the effectiveness of resin sealants with their glass-ionomer counterparts placed by ART. The aim of the present study was to compare caries prevention with high-viscosity GIC sealants placed according to the ART procedure and lightcured composite resin sealants after 3 years under field conditions. Materials and Methods Patients and study design The study was conducted in a boarding school in the city of Kırıkkale, Turkey, which is located near the capital city Ankara in Middle Anatolia. Four experienced dentists placed the sealants, without chair-side assistance, on the school premises between late 2004 and early All dentists were experienced in placing composite resin sealants. Three dentists had no previous experience in applying the high-viscosity GIC sealants according to the ART procedure. The operators were trained and graded regarding selection, treatment procedures, and practice before the study. Each patient was treated by one of the operators and all treatments were done on school premises. Composite resin and GIC sealant materials were applied randomly to the first permanent molars of children aged 7 11 years. The study protocol was accepted by the National Educational Management of Kirikkale city. Parental consent was obtained in writing through the school authorities. Children received instructions on good oral health care and were individually shown how to clean their teeth prior to the start of the treatment. The teeth considered to be at risk of caries were sealed randomly with composite resin or GIC sealants. If one sealant was placed on one side, the other sealant was placed on the other side. The inclusion criteria were: (1) sound pits and fissures in fully erupted first molars; and (2) pits and fissures diagnosed with an early enamel lesion. The exclusion criteria were: (1) partly erupted first molar; (2) an obvious cavity in the occlusal surface; and (3) the presence of a restoration or a sealant (or part of it) in the pit and fissure system. Sealant procedures ART GIC sealant: The teeth were isolated using cotton rolls. The occlusal surface was cleaned with a probe, conditioned with polyacrylic acid (3M/ESPE, Minneapolis, USA) for 15 seconds, washed with water-moistened cotton pellets, and dried with a manual air pump. The GIC (Ketac Molar, 3M/ESPE) was hand-mixed, according to the manufacturer s instructions. The GIC mixture was applied to the occlusal surface with and pressed into the pits and fissures using a gloved finger. Excess material was removed after bite registration. The sealant was then coated with Vaseline. Children were instructed not to eat for at least 1 hour. Resin-based sealant: Teeth were isolated with cotton rolls and then etched with 37% phosphoric acid (Super Etch, SDI Limited, Bayswater, Australia) for 20 seconds. The occlusal surface was washed with water-moistened cotton pellets and dried with a manual air pump. Composite resin sealant (Fissurit F, Voco, Cuxhaven, Germany) was applied and cured (CromaluxE-Plus, Mega Physik, Rastatt, Germany) according to the manufacturer s instructions. All of the sealed teeth were observed using a buccal mirror and explorer after 3 years, with the following scoring system: 1, total retention; 2, J Formos Med Assoc 2009 Vol 108 No

3 A.A. Oba, et al partial loss; and 3, total loss. The caries evaluation criteria were: 1, present; and 2, absent. The data were analyzed by one-way analysis of variance. Results Two hundred and seven sealants (91 in GIC group and 116 in resin group) were applied to 70 children initially, and 137 sealants in 41 children were available after 3 years. Fifty-six teeth in the GIC group and 81 in the resin group were examined. The resin retention rates are shown in Table 1. After 3 years, none of the resin sealants showed total retention. However, in the GIC group, the total retention rate was 19.6%. In the GIC group, 14 of 56 teeth showed partial loss of sealant, whereas, only 5 of 81 teeth showed partial loss in the resin group. In the GIC group, 55.3% of the teeth showed total loss of sealant, and in the resin group, the total loss was 93.8%. The difference between the all three parameters was statistically significant (p < 0.01). The occurrence of new caries did not differ significantly between the GIC and the resin group (Table 2; p > 0.05). Only six of 56 teeth in the GIC group and eight of 81 teeth in the resin group showed signs of caries. Table 1. Table 2. Sealant group Retention of sealants after 3 years* Sealant Total Partial Total group retention loss loss GIC (n = 56) 11 (19.6) 14 (25.0) 31 (55.3) Resin (n = 81) 0 (0) 5 (6.1) 76 (93.8) Total (n = 137) 11 (8.0) 19 (13.8) 107 (78.1) *Data presented as n (%). GIC = glass ionomer cement. Occurrence of carious teeth after 3 years* Absent Caries Present GIC (n = 56) 50 (89.2) 6 (10.7) Resin (n = 81) 73 (90.1) 8 (9.8) Total (n = 137) 123 (89.7) 14 (10.2) *Data presented as n (%). GIC = glass ionomer cement Discussion The present study showed that retention rate (total and partial) of the GIC sealant applied by ART was significantly higher than that of the composite resin counterparts in split-mouth design after 3 years. Although we had not expected this result, the complete disappearance of resin sealants could have resulted from the insufficient moisture control during the procedure. To solve this problem we used a manual air pump, but this was not successful. This result agrees with previous conclusions that the retention rate of the resin sealants is highly related to moisture control Despite differences in design, many clinical studies of resin sealants have achieved retention rates of > 90% after 1 year and > 80% after 10 years. 15,16 In contrast to this, surveys of the quality of sealants under field conditions or national health regulations have shown much higher rates of imperfect sealants, in the range of 50 80%, which is similar to the rate found in our study. 17,18 Therefore, the results of the present study are more in line with the reality of sealants than with controlled clinical trials. This is also true for the failure rate of sealants (defined as subsequent carious teeth). Clinical studies have annual failure rates of %, which is much lower than the mean of nearly 30% in our study. Only Rajic et al 22 and Vrbic 23,24 have reported high failure rates of 6 18% in Croatian children, where high caries activity, little fluoride use, and technical difficulties such as moisture control might have been severe problems. Similarly, the reasons for the high failure rate seen in our study are no fluoride use, limited technical facilities, and skill differences between the four dentists who applied the sealants. The complete loss of high-viscosity GIC sealants in the present study after 3 years (19.6%) is considerably lower than that reported in several previous studies using comparable glass ionomer sealants (28 90%), 7,8,25,26 but similar to the 16% in another study. 10 There are a number of factors that could explain this. First, different types of GIC were used and the variable 846 J Formos Med Assoc 2009 Vol 108 No 11

4 Glass ionomer and resin fissure sealants properties of the different cements might be relevant, as wear rates vary between them. Second, nearly all of the previous studies were conducted in dental clinics with access to suction and good moisture control; however, this was not the case in the present field trial. Finally, the fissure patterns of permanent teeth are different, being in general deeper, which could make it easier for sealants to be retained. Moreover, as discussed in a recent similar study, 27 this could have resulted partly from the fact that the high-viscosity glass ionomer sealants in two of the previous studies 25,26 were placed in adolescents, who are generally easier to treat than the elementary school children. The GIC sealant that has been studied most often (Fuji III ; GC) has a low viscosity. 9,10 In recent years, high-viscosity restorative GICs have been used as sealant materials. 7,28 Dental therapists and dentists have placed these sealants, as part of the ART approach, in first and second molars in adolescents. 7,8 After 3 years, the sealant retention rate of these so-called ART GIC sealants appeared to be higher than that of low-viscosity sealants. The complete loss of high-viscosity GIC sealants in the present study after 3 years (45%) was somewhat higher than that reported previously for comparable sealants after 3 years (28% and 29%). 7,8 The high-viscosity GIC sealants in the two latter studies were placed by one or two experienced dentists, who had previous experience of field conditions. In our study, although all four dentists had at least 5 10 years clinical experience, only one had field experience of ART and/or sealant application. This could explain why ART GIC sealants were worst than expected in this study. In a recent 3-year follow-up study, Poulsen et al 29 also used the same methodology, and reported that the GIC sealant was completely lost in almost 90% of the teeth, compared with < 10% loss of resin sealant. When compared with our results, the retention rate for GIC sealants was worse, but for resin sealants, it was better than in our study. It could be that the retention of resin sealants was higher than that in our study because all treatments were performed in a wellequipped dental center. When compared with two recent studies of resin and glass ionomer fissure sealant modalities, our study clearly showed that the ART GIC sealants were equivalent to their resin counterparts with respect to preventing caries. 30,31 This result agrees with many other clinical trials Based on the present results, we conclude that, under field conditions where moisture control might not be effective, a high-viscosity and less technique-sensitive GIC can be used as a feasible and effective sealant, which is equivalent to its resin counterparts. References 1. Petersson GH, Bratthall D. The caries decline: a review of reviews. Eur J Oral Sci 1996;104: Kaste LM, Selwitz RH, Oldakowski RJ, et al. Coronal caries in the primary and permanent dentition of children and adolescents 1 17 years of age: United States, J Dent Res 1996;75: Simonsen RJ. Pit and fissure sealant: review of the literature. Pediatr Dent 2002;24: Smith AJE, Chimiba PD, Kalf-Scholte S, et al. Clinical pilot study on new dental filling material and preparation procedures in developing countries. Community Dent Oral Epidemiol 1990;18: World Health Organization. Revolutionary new procedure for treating dental caries. Press release WHO/28, April 7, Yip HK, Smales RJ. Glass ionomer cements used as fissure sealants with the atraumatic restorative treatment (ART) approach: review of literature. Int Dent J 2002;52: Holmgren CJ, Lo ECM, Hu DY, et al. ART restorations and sealants placed in Chinese school children: results after three years. Community Dent Oral Epidemiol 2000; 28: Frencken JE, Makoni F, Sithole WD. ART restorations and glass-ionomer sealants in Zimbabwe: survival after 3 years. Community Dent Oral Epidemiol 1998;26: Karlzen-Reuterving G, van Dijken JWV. A 3-year follow-up of glass ionomer cement and resin fissure sealants. J Dent Child 1995;62: Mejàre I, Mjör IA. Glass ionomer and resin based fissure sealants: a clinical study. Scand J Dent Res 1990;98: Forss H, Halme E. Retention of a glass ionomer cement and a resin-based fissure sealant and effect on carious J Formos Med Assoc 2009 Vol 108 No

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