V.K. Prashanth*, L.Nagesh**, Anil V. Ankola*** , Pradnya Hegde****, Shushma Nayak*****
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J Pak Dent Assoc 2010;19(1): 24 - 29
To compare and evaluate the retention rate, marginal integrity and surface structure of glass-ionomer [Fuji III] with resin based fissure sealants [3M ESPE].
This study had a spilt mouth design using contralateral mandibular permanent first molars with well defined fissures and was conducted on 50 school children. First half of the children were randomly selected and applied glass-ionomer sealant on one side followed by resin-based sealant on contralateral tooth and vice versa. Quality evaluation was done by calibrated examiner on 4th, 8th and 12th month after application of sealant. Mann-Whitney test was done for the treatment difference and Wilcoxon signed ranks test was done for evaluation of sealants at different intervals and significance level was set at 0.05.
At 12th month evaluation, extensive loss of sealant was recorded in 44% of the glass-ionomer sealant, where as none of the tooth scored extensive loss for light cure resin-based sealant (p-0.0001). Light cure resin-based sealant (88%) had better adaptation compared to glass-ionomer sealant (28%) (p-0.05). Only 6% scored smooth surface in glass-ionomer compared to 66% in light cure resin-based sealant (p-0.001).
Since the retention, marginal integrity and surface structure of glass-ionomer seems to be clearly lower than that of resin-based sealant, more clinical evidence of the effect of glass ionomer on caries development after the loss of the sealant material should be collected before glass-ionomer sealants can be recommended for general use.
glass-ionomer sealant, light-cure resin based sealant, retention, marginal integrity, surface texture and 1st permanent mandibular molar.
Changes in the epidemiological pattern of dental caries have been observed in the last few decades1. Developed countries showed a drop in the dental caries incidence because of preventive procedures. However, even in the developed countries where there is an effective control for this disease, 25% of the population is still considere at high risk because of the different decline patterns between occlusal and smooth surface caries2.
The complex morphology of the occlusal surface provides a greater vulnerability to the occurrence of pit and fissure caries, mainly in first few years after dental eruption. Pit and fissure caries forms the bulk of caries prevalence2. Pit and fissure sealants have been developed in an attempt to prevent carious lesions in the occlusal surface of teeth; there is strong support for the view that the fissure sealants are effective in dental caries prevention3. Pit and fissure sealant is a “cement or resin material which is introduced into unprepared occlusal pit and fissure of caries susceptible teeth forming a mechanical and physical protective layer against the action of acid producing bacteria and their substrate”4. For most of the period since the introduction of sealant the focus has been on Bis-GMA resin based materials. Resin based sealants have been tested on many occasions and have generally been shown to be an effective method of caries prevention for children and young adults. The efficacy of these resin sealants in preventing caries has been associated with the duration and degree of sealant retention5.
Resin based sealants are popular but they are technique sensitive. Most of them do not release fluoride ions, which might provide additional protection against caries6. Glass-ionomer cements which are specifically developed for fissure sealing are gaining popularity, they have certain unique advantages above resin based sealants such as bio-compatibility, chemical bonding with enamel and dentin and release of fluoride ions. They are not sensitive to moisture contamination compared to resin-based sealants7. Several studies have reported in the literature related to the adhesion rate of fissure sealants. Poor retention and loss of sealant is the most common drawback noticed with sealant. Hence, this study was conducted for Quality evaluation (retention rate, marginal integrity and surface structure) of glass-ionomer fissure sealants [Fuji III] and resin-based fissure sealant [3M ESPE].
The sample size was based on the proportion of partial retention rates from a previous study8. The proportion of (partial plus complete) retention rate for light cure was 62% and for GIC was 90% and required sample size was estimated to be 35 for each arm for recording the difference in retention rates. Since our study had an additional criterion to assess the quality of the sealants we also considered the “sealants needing retreatment” from previous study. The proportion 62% and 34% as in the aforementioned study were used for sample size estimation and 49 patients per study arm were adequate for the study.
Sample selection: This clinical trial was conducted in the Department of Preventive and Community Dentistry. 50 children belonging to 6-9years at the start of the study were recruited from a primary school who met the inclusion and exclusion criteria. Inclusion criteria comprised a minimum age of 06years where 1st permanent mandibular molars were erupted, children with at least one pair of permanent mandibular first molars with well defined fissures and entire occlusal surface visible in the mouth
children. Prior to start of the study informed consent was obtained from the parents and school authority. The study plan was approved by the institutional ethical committee.
Study design: A randomized spilt mouth design using contralateral mandibular permanent first molar teeth.
Instruments and materials used were Plane mouth mirrors, CPI probes, Cement carrier, Applicator tips, Cleaning rubber cups, Suction tips, Pumice, Mixing pad, Plastic spatula, Tweezers, Fuji III glass-ionomer cement, Light cure resin sealant [3M ESPE], Kidney trays, Disposable tumblers, Gauze and cotton rolls and Gloves and mouth masks. Instruments were sterilized using Electrical sterilizers and Autoclave in the department.
Diagnostic method and criteria: Children were examined in the month of June, 2004 for permanent 1st mandibular molars with well defined fissures by an operator, which allowed a separate diagnosis of clinically non-cavitated lesions to be made as mentioned above. Probing was performed with CPI probe using very slight pressure, radiographs were not used in the study.
Criteria for Clinical Evaluation: All examinations were done in the clinical facilities of the department with child seated in a dental chair with good operating light, using mouth mirror and probe and drying with compressed air. The following scoring criterion was employed for quality evaluation of the sealants:
Extension [anatomical form]: A=complete extension [retention]: sealant covers all parts of the grooves and the fossae. B=absence or loss of sealant restricted to the peripheral part of one or more grooves. C=absence or loss of sealant in one or more grooves including one fossa. D=extensive loss of sealant including grooves and two or all three fossae or absence of sealant.
Enamel adaptation [marginal integrity].
A=sealant adapts well, a smooth passage between sealant and enamel along the entire periphery. B=some vertical over contouring but no obvious crevices. C=vertical over contouring with crevices, but no cracks or fractures. D=poor adaptation with cracks, fractures or flakes.
B=slightly rough and pitted surface.
C=rough surface with irregular grooves.
D=rough surface with fractures and flakes
Clinical evaluation was done by calibrated examiner 4th Author, blinded to the type of sealants applied and was evaluated at 4th, 8th and 12th month’s interval after the application of sealant
A single trained dentist carried out the application of the fissure sealants with a trained assistant.The materials used were Fuji III, a glass-ionomer sealant (GC Dental Industrial Corp..Tokyo, Japan) and Clinpro, a light cure Bis-GMA resin-based sealant (3M ESPE Dental product, st. paul Mn,USA).
Before starting the actual study, the operator carried out sealant application on 5 children (10 teeth) to understand children co-operation and accessibility, duration of time required for application of the sealant, and to know the handling properties of sealant materials used. The application of the sealant was carried out under direct supervision of 2nd Author, and these children were not included in the main study
50 school children were included in the main study, first half of the school children were randomly selected and applied glass-ionomer sealant on one side followed by resin-based sealant on contralateral tooth and vice versa. Prior to applying resin-based sealant the teeth were cleaned using rotating brush and pumice, rinsed thoroughly and dry field was maintained and then etched with 37% phosphoric acid for 30 seconds. After washing and drying the resin sealant was applied and cured according to manufacturers’ instructions. Surface of teeth to be sealed with glass-ionomer sealant were cleaned as mentioned previously. The glass-ionomer sealant was mixed and applied to the tooth and excess cement was removed. A waterproof varnish was applied over the cement as recommended by the manufacturer. The high point were checked and corrected before sending the patient. No re-sealing was done at follow-up examination.
Analysis of results:
Mann-Whitney test was done for the treatment difference and Wilcoxon signed ranks test was done for evaluation of sealants at different intervals. A difference at the 5% level of probability was considered statistically significant.
At the commencement of the study, sealant was applied to 50 children of whom all were available for 4th month evaluation, 49 children were available for 8th month and 47 children at 12th month evaluation. Quality evaluation of sealants was done according to anatomical form, enamel adaptation and surface texture
EXTENSION (ANATOMICAL FORM):
Complete extension that the sealant covers all parts of the grooves and the fossae was seen in100% LCR (Mean = 1.0 ±0.0) sealant when compared to 64% for GIC (Mean = 1.5 ±0.8) sealant at 4th month evaluation (p-0.0001). 32.5% scored extensive loss for GIC (Mean = 2.4 ±1.2) sealant compared to none for LCR (1.1 ±0.3) sealant at 8th month evaluation (p-0.0001). Only 17% scored complete retention for GIC (Mean = 2.3 ±1.1) sealant compared 74% for LCR (Mean = 1.3 ±0.5) sealant at 12th month evaluation (p-0.0001). (Table I, Fig 1&2)
Complete well adaptation of sealant i.e a smooth passage between sealant and enamel along the entire periphery was seen in LCR (Mean = 1.0 ±0.0) sealant compared to 74% in GIC (Mean = 1.3 ±0.6) sealant at 4th month evaluation (p-0.0001). 98% of LCR (Mean = 1.0 ±0.1) sealant scored well adaptation compared to 59% for GIC
(Mean = 1.1 ±0.3) sealant at 8th month evaluation (p-0.063). Only 30% of GIC (Mean = 1.6 ±0.8) sealant scored well adaptation compared to 87% for LCR (Mean = 1.1 ±0.3) sealant at 12th month evaluation (p-0.002) (Table II, Fig III)
Entire smooth surface was scored in 98% of LCR (Mean = 1.02 ±0.1) sealant compared to 62% in GIC (Mean = 1.5 ±0.6) sealant at 4th month evaluation (p-0.0001). 12% of LCR (Mean = 1.1 ±0.3) sealant scored slightly rough and pitted surface compared to 38% for GIC (Mean = 1.6 ±0.6) sealant at 8th month evaluation (p-0.0001). Only 6.5% of GIC (Mean = 2.0 ±0.5) sealant scored entire smooth surface compared to 70% for LCR (Mean = 1.3 ±0.5) sealant at 12th month evaluation (p-0.0001) (Table III, Fig IV)
Overall Quality Evaluation Of Glass-Ionomer And Resin-Based sealant showed significant statistical difference at follow up examination and also showed significant
difference when compared within the groups (Table IV,).
Overall comparison of retention rate of glass-ionomer and resin based sealants did not vary according to gender and quadrant wise application. (Table V and VI,).
The present study aimed to compare the retention rate of Fuji III glass-ionomer and light cured resin-based sealants. The results revealed that there is a significant difference between these two sealants. The experimental design was an important aspect of the present study. The spilt-mouth design allows comparison between the two groups that are less biased. Also, randomization of the quadrants between the types of sealants used allows equal distribution of the variables between the groups. At 12 months evaluation, almost 70% of LCR sealant was completely retained. Mejare and Mjor9, Poulsen S. et al4, Forss H, et al10 and Kervanto-sppala S et al11 showed similar results where as Gunlog Karlzen-Reaterving et al12 reported greater retention of 97.2%. Ripa13 reported on 24 clinical trials when Bis-GMA resin (light cured and chemically cured) was used as sealants on premolars and molar teeth, One year retention rate ranged from 18% to 99% with the majority being greater than 80%. Retention rates of resin sealant after one year in the present study are comparable with the previous studies obtained after same period of observation, indicating comparable efficiency in the clinical technique. 16% of the glass-ionomer cement was
clinical trials on glass-ionomer sealant supported the above presented suggestion. Arrow and Riordon5 and Seppal 11 showed a clearly cariostatic effect of glass-ionomer sealant (RR=0.19) after 3.5 years in spite of poor retention rate (20.3%).Craig mentioned this trait as being especially advantageous for newly erupted teeth where enamel was relatively porous. Enamel adaptation and surface texture are directly related to the retention rate, Poor enamel adaptation and surface texture can explain poor retention rate of glass-ionomer sealant compared to resin-based sealant
The results of this study showed that resin-based fissure sealant is superior to glass-ionomer fissure sealant when 12-month retention was compared. There were several problems in connection with the use of glass-ionomer sealants. Further improvement on the glass-ionomer sealants should be encouraged in order to produce a more wear resistance to withstand the occlusal forces. Since the retention, marginal integrity and surface structure of glass-ionomer sealants seems to be clearly lower than that of resin-based materials, more clinical evidence of the effect of glass ionomer material on caries development after the loss of the sealant material should be collected before glass-ionomer sealants can be recommended for general use
The authors acknowledge the expert advice of Mr. Sangam Biostatistician and Dr. Ravi Shirahatti for his guidance to write this article
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