DIAGNOSIS/TREATMENT/PROGNOSIS
ARTICLE ANALYSIS & EVALUATION ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION Effectiveness of school-based dental sealant programs among children from low-income backgrounds in France: A pragmatic randomised clinical trial. Muller-Bolla M, Lupi-Pegurier L, Bardakjian H, Velly AM. Community Dent Oral Epidemiol 2013;41(3):232-42.
School-based Dental Programs Prevent Dental Caries in Children at High Risk for Caries From Low Socioeconomic Backgrounds SUMMARY Subjects The study population comprised 276 first- and second-graders, age 6– 7 years, attending 16 elementary schools located in low socioeconomic zones in Nice, France. All children in the relevant class were invited to participate.
REVIEWER Ivor G. Chestnutt, BDS, MPH, PhD, FFPH, FDS RCSEd
PURPOSE/QUESTION How effective is a school-based dental sealant program for preventing dental caries in French children from low-income backgrounds?
SOURCE OF FUNDING Dentsply, the city of Nice, and the Conseil General des Alpes Maritimes funded this study.
TYPE OF STUDY/DESIGN Split-mouth randomized clinical trial
LEVEL OF EVIDENCE Level 2: Limited-quality, patientoriented evidence
STRENGTH OF RECOMMENDATION GRADE Not applicable
Key Exposure/Study Factor The key exposure was the placement of a resin-based dental sealant on the occlusal surface of one of a pair of mandibular and/or maxillary first permanent molars. The contralateral unsealed molar acted as control in this split-mouth study. A total of 457 pairs of permanent first molars in 276 children (133 girls and 143 boys) were included. Active caries in permanent or primary teeth, visible plaque, and Streptococcus mutans and Lactobacillus counts were recorded at baseline to assess individual caries risk.
Main Outcome Measure The main outcome measure was the occurrence of new caries (ICDAS code 3-6) at the 1-year follow-up. The secondary outcome was the sealant’s status after 1 year of follow-up, specifically, total retention, partially lost, or fully lost. The sealant was considered partially lost if it did not cover all occlusal pits and fissures.
Main Results At 1-year follow-up, 253 children (421 tooth pairs) remained in the study. First permanent molars that received sealants were less at risk for developing new caries lesions after 1 year of follow-up compared with those from the control group (OR = 0.26, 95% CI: 0.14–0.49). The effect of the sealants was significant only when the analyses included subjects with active caries or a high S. mutans count at baseline. At the 1-year follow-up, total retention was recorded in 52.7% (n = 222) of the treated teeth.
Conclusions The 1-year effectiveness of a school-based dental sealant program in preventing dental caries was demonstrated in children from low socioeconomic areas. The selection of schoolchildren according to individual caries risk factors should be considered in such programs.
J Evid Base Dent Pract 2014;14:36-38
COMMENTARY AND ANALYSIS
1532-3382/$36.00 Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jebdp.2014.01.009
Two background factors are of relevance to the study reported here. First, the relationship between dental caries and social and economic
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
deprivation is undisputed, and as oral health has improved, dental caries has become concentrated in underprivileged populations. Second, the occlusal surface of first permanent molars is the most highly cariessusceptible tooth surface, particularly immediately posteruption. By adolescence, 80% of caries lesions are found on the occlusal surface of first permanent molars.1 Combined, these facts mean that there are highly susceptible tooth surfaces in at-risk populations. Prevention targeted at these particular tooth surfaces is therefore important. The clinical effectiveness of resin-based fissure sealants as a caries preventive treatment is beyond doubt.2 The question therefore to be answered by this study is not, ‘‘Do fissure sealants work?’’ but rather, ‘‘Do they work in the context of a pragmatic school-based dental sealant program (SBDSP)?’’ The authors make the point that establishing SBDSPs in high-risk schools has the potential to eliminate racial and economic disparities linked to sealant provision. While SBDSPs have been widely used, particularly in the United States, relatively few studies have investigated the clinical effectiveness of fissure sealants when delivered in the context of an SBDSP – indeed the authors of this paper claim that the effectiveness of an SBDSP has never been demonstrated with a randomized clinical trial. For this reason, a pragmatic clinical trial, where the sealants are placed under conditions of a real program, is justified, as it will present results that are more generalizable to ‘‘real world’’ use. The study reported here has been conducted satisfactorily and is well described. Adequate steps have been taken to control for confounding and bias, and the authors’ conclusions on the effectiveness of an SBDSP are justified. There are, however, some features of this study that are worth commenting on further. First, the outcome measures were recorded after only 1 year. While recognizing that the occlusal surfaces of first permanent molars are most susceptible to decay immediately after they erupt, 12 months is a very short period for follow-up in a field trial. It will be interesting to see the effects after a longer period should the researchers continue their trial for the more conventional 24 or 36 months. The second issue that merits comment is the low sealant retention rate achieved. Total retention at 12 months was only 52.7% (n = 222) of treated teeth. This is very much lower than the level of retention reported in a recent Cochrane Review of sealant effectiveness where four of seven studies reported retention rates of 90% at 12 months, and after 48–52 months, the complete retention of resin-based sealants was 70% in three of five studies. The authors of this study discuss their low retention rates and probably rightly ascribe
Volume 14, Number 1
this to the conditions in which the sealants were applied, specifically, in the school’s infirmary using portable equipment, including an air-water syringe. Under such circumstances it is more difficult to achieve the high degree of moisture control and isolation post-etching that is so necessary for effective adhesion of the sealant. This is important not only from a clinical perspective but also in relation to the overall organization and effectiveness of a SBDSP. Such programs can be totally school-based, as was the case here. The alternative is to identify children suitable for sealant therapy in school but then to refer them to a dental office for sealant placement. This has the advantage of a much greater degree of moisture control than can be achieved in a conventional operatory. The problem then, however, is how to engage the parents of children in low-income areas to take them to see a dental professional in a clinic, assuming that such a service is available. An alternative possible solution is to use a mobile dental clinic, equipped with a conventional dental chair and powerful aspirating facilities, and to drive this to the school, as happens, for example, in the Designed to Smile Programme in Wales, UK.3 Another important issue in relation to SBDSPs is determining which children will benefit from dental sealants. In this study, where a high-risk population approach was taken, children in schools in low socioeconomic status areas were recruited to the study. However, even there, 33.5% of the children were totally caries-free in their permanent and deciduous dentition. In the study, all children whose parents consented were provided with sealants. The authors reported that at 12 months the effectiveness of the sealants was only statistically significant when the analyses included subjects with active caries or high S. mutans counts at baseline. This led them to conclude that selecting children according to individual caries risk factors should be considered in a SBDSP. If this recommendation is to be followed, this means that not only should SBDSPs be targeted at high-risk schools, but the program should then be further targeted at high-risk children within the school. Practically this may lead to logistical and ethical issues that need to be addressed in setting up the program, where some children are offered sealants and others are not. In addition to the clinical and practical issues surrounding SBDSPs, the issue of economics arises. The current study makes no mention of the economic costs and benefits of the program – it is hoped that the authors will report those data as well. These issues aside, this is a worthwhile study that adds to our knowledge about the practicalities of delivering a long-established and effective preventive treatment in a school setting.
37
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
REFERENCES
REVIEWER
1. Chestnutt IG, Sch€afer F, Jacobson APM, Stephen KW. Incremental susceptibility of individual tooth surfaces to dental caries in Scottish adolescents. Community Dent Oral Epidemiol 1996;24:11-6. 2. Ahovuo-Saloranta A, Forss H, Walsh T, et al. Sealants for preventing dental decay in the permanent teeth. Cochrane Database Syst Rev 2013;(3):CD001830. http://dx.doi.org/10.1002/14651858. CD001830.pub4. 3. Designed to Smile. A National Oral Health Improvement Programme. www.designedtosmile.co.uk/home.html.
Ivor G. Chestnutt, BDS, MPH, PhD, FFPH, FDS RCSEd Professor and Honorary Consultant in Dental Public Health, Cardiff University School of Dentistry, College of Biological and Life Sciences, Heath Park, Cardiff, CF14 4XY Wales, UK, Tel.: þ29 2074 6680; fax: þ29 2074 6489 [email protected]
38
March 2014
ARTICLE ANALYSIS & EVALUATION ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION Effectiveness of school-based dental sealant programs among children from low-income backgrounds in France: A pragmatic randomised clinical trial. Muller-Bolla M, Lupi-Pegurier L, Bardakjian H, Velly AM. Community Dent Oral Epidemiol 2013;41(3):232-42.
School-based Dental Programs Prevent Dental Caries in Children at High Risk for Caries From Low Socioeconomic Backgrounds SUMMARY Subjects The study population comprised 276 first- and second-graders, age 6– 7 years, attending 16 elementary schools located in low socioeconomic zones in Nice, France. All children in the relevant class were invited to participate.
REVIEWER Ivor G. Chestnutt, BDS, MPH, PhD, FFPH, FDS RCSEd
PURPOSE/QUESTION How effective is a school-based dental sealant program for preventing dental caries in French children from low-income backgrounds?
SOURCE OF FUNDING Dentsply, the city of Nice, and the Conseil General des Alpes Maritimes funded this study.
TYPE OF STUDY/DESIGN Split-mouth randomized clinical trial
LEVEL OF EVIDENCE Level 2: Limited-quality, patientoriented evidence
STRENGTH OF RECOMMENDATION GRADE Not applicable
Key Exposure/Study Factor The key exposure was the placement of a resin-based dental sealant on the occlusal surface of one of a pair of mandibular and/or maxillary first permanent molars. The contralateral unsealed molar acted as control in this split-mouth study. A total of 457 pairs of permanent first molars in 276 children (133 girls and 143 boys) were included. Active caries in permanent or primary teeth, visible plaque, and Streptococcus mutans and Lactobacillus counts were recorded at baseline to assess individual caries risk.
Main Outcome Measure The main outcome measure was the occurrence of new caries (ICDAS code 3-6) at the 1-year follow-up. The secondary outcome was the sealant’s status after 1 year of follow-up, specifically, total retention, partially lost, or fully lost. The sealant was considered partially lost if it did not cover all occlusal pits and fissures.
Main Results At 1-year follow-up, 253 children (421 tooth pairs) remained in the study. First permanent molars that received sealants were less at risk for developing new caries lesions after 1 year of follow-up compared with those from the control group (OR = 0.26, 95% CI: 0.14–0.49). The effect of the sealants was significant only when the analyses included subjects with active caries or a high S. mutans count at baseline. At the 1-year follow-up, total retention was recorded in 52.7% (n = 222) of the treated teeth.
Conclusions The 1-year effectiveness of a school-based dental sealant program in preventing dental caries was demonstrated in children from low socioeconomic areas. The selection of schoolchildren according to individual caries risk factors should be considered in such programs.
J Evid Base Dent Pract 2014;14:36-38
COMMENTARY AND ANALYSIS
1532-3382/$36.00 Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jebdp.2014.01.009
Two background factors are of relevance to the study reported here. First, the relationship between dental caries and social and economic
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
deprivation is undisputed, and as oral health has improved, dental caries has become concentrated in underprivileged populations. Second, the occlusal surface of first permanent molars is the most highly cariessusceptible tooth surface, particularly immediately posteruption. By adolescence, 80% of caries lesions are found on the occlusal surface of first permanent molars.1 Combined, these facts mean that there are highly susceptible tooth surfaces in at-risk populations. Prevention targeted at these particular tooth surfaces is therefore important. The clinical effectiveness of resin-based fissure sealants as a caries preventive treatment is beyond doubt.2 The question therefore to be answered by this study is not, ‘‘Do fissure sealants work?’’ but rather, ‘‘Do they work in the context of a pragmatic school-based dental sealant program (SBDSP)?’’ The authors make the point that establishing SBDSPs in high-risk schools has the potential to eliminate racial and economic disparities linked to sealant provision. While SBDSPs have been widely used, particularly in the United States, relatively few studies have investigated the clinical effectiveness of fissure sealants when delivered in the context of an SBDSP – indeed the authors of this paper claim that the effectiveness of an SBDSP has never been demonstrated with a randomized clinical trial. For this reason, a pragmatic clinical trial, where the sealants are placed under conditions of a real program, is justified, as it will present results that are more generalizable to ‘‘real world’’ use. The study reported here has been conducted satisfactorily and is well described. Adequate steps have been taken to control for confounding and bias, and the authors’ conclusions on the effectiveness of an SBDSP are justified. There are, however, some features of this study that are worth commenting on further. First, the outcome measures were recorded after only 1 year. While recognizing that the occlusal surfaces of first permanent molars are most susceptible to decay immediately after they erupt, 12 months is a very short period for follow-up in a field trial. It will be interesting to see the effects after a longer period should the researchers continue their trial for the more conventional 24 or 36 months. The second issue that merits comment is the low sealant retention rate achieved. Total retention at 12 months was only 52.7% (n = 222) of treated teeth. This is very much lower than the level of retention reported in a recent Cochrane Review of sealant effectiveness where four of seven studies reported retention rates of 90% at 12 months, and after 48–52 months, the complete retention of resin-based sealants was 70% in three of five studies. The authors of this study discuss their low retention rates and probably rightly ascribe
Volume 14, Number 1
this to the conditions in which the sealants were applied, specifically, in the school’s infirmary using portable equipment, including an air-water syringe. Under such circumstances it is more difficult to achieve the high degree of moisture control and isolation post-etching that is so necessary for effective adhesion of the sealant. This is important not only from a clinical perspective but also in relation to the overall organization and effectiveness of a SBDSP. Such programs can be totally school-based, as was the case here. The alternative is to identify children suitable for sealant therapy in school but then to refer them to a dental office for sealant placement. This has the advantage of a much greater degree of moisture control than can be achieved in a conventional operatory. The problem then, however, is how to engage the parents of children in low-income areas to take them to see a dental professional in a clinic, assuming that such a service is available. An alternative possible solution is to use a mobile dental clinic, equipped with a conventional dental chair and powerful aspirating facilities, and to drive this to the school, as happens, for example, in the Designed to Smile Programme in Wales, UK.3 Another important issue in relation to SBDSPs is determining which children will benefit from dental sealants. In this study, where a high-risk population approach was taken, children in schools in low socioeconomic status areas were recruited to the study. However, even there, 33.5% of the children were totally caries-free in their permanent and deciduous dentition. In the study, all children whose parents consented were provided with sealants. The authors reported that at 12 months the effectiveness of the sealants was only statistically significant when the analyses included subjects with active caries or high S. mutans counts at baseline. This led them to conclude that selecting children according to individual caries risk factors should be considered in a SBDSP. If this recommendation is to be followed, this means that not only should SBDSPs be targeted at high-risk schools, but the program should then be further targeted at high-risk children within the school. Practically this may lead to logistical and ethical issues that need to be addressed in setting up the program, where some children are offered sealants and others are not. In addition to the clinical and practical issues surrounding SBDSPs, the issue of economics arises. The current study makes no mention of the economic costs and benefits of the program – it is hoped that the authors will report those data as well. These issues aside, this is a worthwhile study that adds to our knowledge about the practicalities of delivering a long-established and effective preventive treatment in a school setting.
37
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
REFERENCES
REVIEWER
1. Chestnutt IG, Sch€afer F, Jacobson APM, Stephen KW. Incremental susceptibility of individual tooth surfaces to dental caries in Scottish adolescents. Community Dent Oral Epidemiol 1996;24:11-6. 2. Ahovuo-Saloranta A, Forss H, Walsh T, et al. Sealants for preventing dental decay in the permanent teeth. Cochrane Database Syst Rev 2013;(3):CD001830. http://dx.doi.org/10.1002/14651858. CD001830.pub4. 3. Designed to Smile. A National Oral Health Improvement Programme. www.designedtosmile.co.uk/home.html.
Ivor G. Chestnutt, BDS, MPH, PhD, FFPH, FDS RCSEd Professor and Honorary Consultant in Dental Public Health, Cardiff University School of Dentistry, College of Biological and Life Sciences, Heath Park, Cardiff, CF14 4XY Wales, UK, Tel.: þ29 2074 6680; fax: þ29 2074 6489 [email protected]
38
March 2014
