Steven Armstrong DDS, PhD
This systematic review with meta-analysis found no conclusive evidence that either resin-modified glass ionomer cement or adhesive resin was superior in preventing dental caries when used as a pit and fissure sealant.
A review using accepted methods finds no difference in caries preventive effectiveness between resin-modified glass ionomer cements and resin-based materials when used as single application fissure sealants for a period up to two years.
Are resin-modified glass ionomer cements (RMGIC) as effective as resin-based fissure sealants when used on permanent teeth for caries prevention?
The authors searched 10 databases for literature relevant to the clinical question. Clinical trials were considered if they were published through April 15, 2009 in English, Portuguese or Spanish. Two reviewers independently reviewed the studies for inclusion, and resolved disagreements by discussion and consensus. They also independently extracted data from the accepted articles for caries preventive effect and performed a quality assessment of the included trials. A meta-analysis of homogenous datasets was completed.
The authors identified 212 articles, from which they included a total of six trials. These trials contained 19 datasets comparing a RMGIC to an adhesive resin, 11 of which were similar enough to be pooled for analyses. No difference in caries-preventive effects were observed at six, 12 and 24 months. The 36-month data came from a single data set, which favored resin-based sealants (relative risk [RR] = 0.93; 95 percent confidence interval (CI) 0.88-0.97, P = 0.002). None of the included trials reported how randomized sequence allocation and allocation concealment was accomplished; completeness of follow-up, however, was deemed adequate for all studies.
Both materials appear to be equally suitable for clinical application as pit and fissure sealants for a period of up to two years. More high-quality randomized control trials should be conducted to obtain conclusive evidence of equivalence or difference in caries prevention.
Source of Funding:
Importance and Context:
A previous systematic review from these authors concluded that glass ionomer cements (GIC) and resin-based sealants demonstrated equivalent caries prevention as pit and fissure sealants. (Yengopal V, Michenautsch S, Bezerra AC and Leal SC. Caries-preventive effect of glass ionomer and resin-based fissure sealants on permanent teeth: a metaanalysis. J Oral Sci 2009;51:373-382.) This systematic review asked the same question regarding RMGIC. Although this systematic review did not specifically address the question of field control or clinical setting during placement, it did compare the caries prevention effectiveness of RMGIC to the highly successful gold standard resin-based sealant. This review was highly relevant because resin sealants, while documented as effective, are underutilized. Although contamination must be avoided, glass ionomer materials (GIC and RMGIC) are more moisture-forgiving than resin-based sealants. Also significant is that this systematic review addressed a patient level effectiveness measure, i.e., caries prevention, and avoided surrogate measures such as sealant retention that for GIC or RMGIC, may not be directly related to caries prevention.
Strengths and Weaknesses of the Systematic Review:
The authors used accepted methods to identify studies using predetermined inclusion/exclusion criteria. Only publications in English, Spanish and Portuguese were included and excluded studies were not listed. They confirmed the appropriateness of pooling studies with accepted methods, but did not perform any separate subset analyses of heterogeneous studies. They evaluated the quality of the included studies, and highlighted the need for improved study design, and reporting.
Strengths and Weaknesses of the Evidence:
Multiple randomized controlled trials with good follow up that measure caries prevention effectiveness are available; however, only one study follows patients beyond 2 years. Early studies evaluating the effectiveness of RMGIs as fissure sealants used a RMGIC lining material that significantly lacks abrasion resistance for occlusal function. One of these studies (Raadal et al 1996) then “diagnosed” molars as carious when explorer "sticking with or without discoloration and dentin involvement" was present, in the apparent absence of fissure sealing material. This technique may not accurately identify the presence of caries. (Penning C, van Amerongen JP, Seef RE, ten Cate JM. Validity of probing for fissure caries diagnosis. Car Res 26(6):445-449.) Available studies do not consistently report: (1) study group caries risk or prevalence (2) randomization methods and allocation concealment, or (3) field control and material application details; all of which limit our ability to analyze and apply the data to our patients.
Implications for Dental Practice:
This systematic review could not confirm any difference in caries prevention effectiveness between RMGIC and resin as fissure sealants. Although further study of appropriately design studies would be helpful, it appears that RMGIC materials, as more moisture tolerant and technique insensitive, may be an appropriate treatment choice. Future clinical trials may show that RMGIC sealants as particularly useful in those clinical situations where ART procedures are indicated. Regardless of material choice, thorough assessment of sealant integrity and effectiveness should occur at risk-based recall schedules.