Journal of Dental Research

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A Longitudinal Evaluation of Fissure Sealants Applied in Dental Practices

A.I. Ismail and P. Gagnon
J DENT RES 1995; 74; 1583
DOI: 10.1177/00220345950740091301

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J Dent Res 74(9): 1583-1590, September, 1995
A Longitudinal Evaluation of Fissure Sealants
Applied in Dental Practices
A.I. Ismail' and P. Gagnon2
'Faculty of Dentistry, Dalhousie University, Halifax, Nova Scotia, Canada B3H 3J5; and 2Facult6 de medecine dentaire, Universite Laval, Cite
universitaire, Ste-Foy, Qu6bec
Abstract. Sealants are highly effective in preventing dental caries
in the pits and fissures of teeth when applied by trained
operators in clinical trials and public health programs. The
effectiveness of fissure sealants when applied in dental practices
is still not known. The purpose of this longitudinal study was to
evaluate the effectiveness of fissure sealants applied in dental
practices in preventing dental caries on occlusal surfaces of first
permanent molars. In 1990, on the Island of Montreal, 911
randomly selected children, from 6 to 9 years of age, were
examined; out of those, 816 and 733 were re-examined in 1991
and 1992, respectively. Only the 733 children with complete
examination records were included in this evaluation. Sealant
applications were either personally paid for or were paid for by
private dental insurers. All children were covered for diagnosis
and restorative care by a publicly financed and universal
insurance program. Dental treatment records were provided by
Quebec's health insurance board. In the epidemiological
examination, the occlusal surfaces of first permanent molars,
which are the only surfaces included in this analysis, were
classified into: sound, non-cavitated and cavitated status,
restored, and sealed. Sealants were evaluated for full or partial
coverage of the occlusal surface and presence of dental caries.
During the first and second years, 11.6% and 17.5% of the
students had new sealants. The number of new sealants placed
during the two years was 507. Children with caries-free status
and whose parents had high school education or higher were
significantly more likely to receive sealants during the study. Of
the sealants found in 1990, 73.5% were still fully sealed after two
years. Compared with sound first permanent molars in 1990,
fully sealed first permanent molars had 75% lower incidence of
new restorations. This pragmatic evaluation of sealants shows
that even when applied in dental practices under uncontrolled
conditions, they were effective in preventing dental caries over a
two-year period.
Key words: prevention, sealants, dental caries, health
services, effectiveness.
Received July 19, 1994; Accepted June 13, 1995
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Introduction
Fissure sealants are highly effective in preventing caries in
pits and fissures (Weintraub, 1989; Simonsen, 1991; Ripa,
1993) and in the management of incipient carious lesions
(Handelman, 1991). However, in spite of the scientific
evidence supporting their effectiveness, their use by
dentists has been limited (Cohen, 1990). In the 1986-87
national survey of children's oral health status in the USA,
only 7.4% of the children aged 5 to 17 years had sealants
(Brunelle, 1989). In a more recent survey in Tennessee, only
10% of schoolchildren had sealants on their teeth (Gillcrist et
al., 1992), and in Scotland, 14.3% of the schoolchildren had
sealants (Stephen et al., 1989), which is higher than the level
of sealants used in other parts of the United Kingdom
(Todd and Dodd, 1985).
There are many reasons for the sparse use of sealants in
caries prevention and management (Cohen, 1990). Findings
from scientific studies are usually not transferred into
practice. Dental practitioners are more influenced about
sealants by opinions of colleagues than by findings
published in research journals. The negative experiences of
dental practitioners with the first generation of sealants
have contributed to the reluctance to abandon their
devotion to amalgam restorations.
In contrast to the first-generation sealants, the retention
of the second-generation sealants (chemically activated BIS-
GMA resins) was found to range between 55% and 85%
after 7 to 8 years (Ripa, 1993). Third-generation sealants
(light-activated BIS-GMA) have not been evaluated as
extensively as the earlier types of resins. The available data
indicate that they are as effective as the second-generation
sealants. After 24 months of follow-up, their retention rates
range from 53% to 97% (Ripa, 1993).
Most of the clinical studies evaluating sealants have
used a proxy outcome (i.e., retention) as a measure of
sealants' effectiveness. Studies that have relied on caries
prevention as an outcome found that sealed teeth have
about a 50% lower caries incidence than unsealed teeth
1583
1584 Ismail & Gagnon
(Ismail et al., 1989; Weintraub, 1989). Pragmatic clinical
evaluation of sealant performance under "real-life" clinical
environments should be carried out for evaluation of their
performance in an uncontrolled clinical condition. There
have been only a few studies that have provided such
information. In Scotland, after one year of follow-up of
sealants applied in community dental clinics or private
practices (Stephen et al., 1989), it was found that 14% of the
sealants were lost, and after three years, 26% of the sealants
were lost. Caries incidence on sealed molars was 50% lower
than in unsealed ones. In Copenhagen (Heidmann et al.,
1990), a retrospective analysis of the dental records of
patients treated in a clinic where sealants were applied,
compared with those of patients from a clinic where
sealants were not used, showed a reduction in the caries
incidence in first permanent molars of 32% and 25% in 12-
year-old girls and boys, respectively. No information was
provided about the type of sealant material used in those
two studies.
The purpose of this study was to evaluate the retention
and effectiveness of sealants in pits and fissures of tooth
surfaces of first permanent molars identified in a
longitudinal study of restorative treatments provided to
children covered by a universal dental insurance program
on the Island of Montreal (< 0.1 ppm F), Quebec. At the
baseline examination, the 911 children in grades 1, 2, and 3
who were examined had, on average, about 1.0 sealed tooth
surfaces. In 1990, 683 sealed occlusal surfaces of first
permanent molars were identified, and 19.6% of the children
had sealants. The majority of the sealants are presumed to
have been applied by private practitioners, because there are
no public health sealant programs in Qu6bec. Only 4.1% of
the children had sought treatment in a University-based
dental clinic.
Materials and methods
Parents of the students who participated in this study gave
written and informed consent allowing the research team to
examine their children and access the dental claims data from
the Quebec health insurance board (Regie de l'assurance-
maladie du Quebec [RAMQ]). The study was reviewed and
approved by the Human Ethics Review Committee of the
Faculty of Dentistry, Dalhousie University.
A detailed description of the sample design and methods
was described in an earlier paper (Ismail et al., 1992), and only
a summary is provided here. In 1989, a study was funded by
the National Health Research and Development Programme,
Federal Department of Health, Canada, to evaluate the
restorative treatment component of the Quebec children's
dental insurance plan, which covers the cost of diagnostic,
restorative, endodontic, and surgical services for all children
between birth and 12 years of age (as of 1992, the upper age
limit was lowered to less than 10 years). Children in this age
range are not covered for preventive care because these
services are provided, in schools, by the regional Departments
of Community Health. The total cost of the program in 1992
was about $64 million (Cdn), with 44% of that money being
used to cover restorative care for children in Quebec (N = 2.4
million). Sealants were not covered by the insurance program.
Therefore, it was surprising to see that, in spite of the lack of
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j Dent Res 74(9) 1995
Table 1. Number of children examined between 1990 and 1992
Grade 1990 1991 1992
1 296
2 297 256
3 318 273 230
4 287 246
5 257
Total 911 816 733
coverage by the public insurance program, sealants were
applied by private dentists. There are two explanations for this
finding: the proliferation of third-party coverage for sealants
and out-of-pocket payments. In 1990, about four out of 10
parents reported that they had paid for dental care for their
children.
Study population
A stratified random sampling method of classrooms was
selected. All elementary schools on the Island of Montreal were
stratified into English- and French-speaking strata. The
targeted number of schools was 20, divided into 16 French-
speaking and four English-speaking schools, with a minimum
number of 75 children, in grades 1, 2, and 3, in each school. If
the school had fewer than 75 children, it was grouped with
another school in the same area. This relative distribution of
children parallels the general distribution of the student
population by linguistic groups on the Island of Montreal. The
targeted sample size was 1,000, and a total of 1,428 children
was selected to compensate for non-response. Out of those,
1,003 parents consented to participate in the study and to allow
access to the dental insurance records. One school principal
refused to participate; therefore, a total of 911 children in 19
schools participated in this study. Out of those, 816 were re-
examined in 1991, and 733 were re-examined in 1992. Table 1
presents the number of students examined in each year. Only
data from the 733 children with a complete dataset (i.e.,
examined in 1990, 1991, and 1992) were included in this
analysis.
Examinations
Two dentists were trained over a period of one year to follow
an examination protocol which included the cleaning of debris
and plaque from the teeth by using an explorer and gauze or
cotton, and drying of the teeth using an air syringe attached to
a portable air compressor. The examination criteria
differentiated between non-cavitated and cavitated carious pits
and fissures. A full description of the criteria is available in a
previous paper (Ismail et al., 1992), and a summary is provided
in Table 2.
Sealed occlusal surfaces were coded separately. Sealed first
permanent molars were classified into fully and partially sealed
status. Fully sealed first permanent molars had sealants
covering all of the pits and fissures on the surface. Also, the
caries status of the sealant margin or the sealed tooth surfaces
was determined according to the criteria described in an earlier
publication (Ismail et al., 1992). In summary, each sealed tooth
surface was also diagnosed for the presence of non-cavitated
j Dent Res 74(9) 1995 Sealants in Dental Practices
Table 2. Definitions of carious lesions
Carious status Tooth Surfaces
Non-cavitated Pits and fissures
Cavitated All tooth surfaces
and cavitated carious lesions. In 1990, when the baseline data
were collected, only 1 sealed first permanent molar had a non-
cavitated carious margin; however, this tooth surface was not
included in this analysis, because the child was not examined in
the following years.
The examiners were trained by examining 200 children who
were not part of the sample selected for the study. The training
examination was conducted three times during the first year of
the project before data collection. The reliability of the
examiners in diagnosing sealants was excellent, with over 98%
of the sealants being re-diagnosed by the same examiner or the
second examiner when the children were re-examined during
data collection.
In pragmatic studies, there is always a question of whether
the identified sealants are "true sealants" or sealants placed
over a restoration (preventive resin restorations). In this
longitudinal study, access was given by the parents to their
children's dental records, filed by dentists with the insurance
board (RAMQ). Out of all first permanent molars reported filled
by dentists to the RAMQ, only 17 were identified by the
epidemiological examiners as sealants with no other restoration
in the same teeth. Given the volume of information processed
and the number of providers, this very low proportion of
misclassification is remarkable.
In addition to the data from the epidemiological
examination, a questionnaire was self-answered by the parents.
The questionnaire asked about the date and place of birth of the
child, consent to access the insurance records, insurance
numbers, gender, use of university dental clinics in Montreal,
and use of out-of-pocket money for dental care. As previously
reported, the insurance database was accessed to obtain dental
claim records for each child, as well as gender, year of
graduation, and the percentage of restorative services out of the
total dental services provided to all the children seen by each
dentist and reported to the insurance board. The restorative
percentages included information from all the children seen by
the dentists, not only those who were included in this study.
Statistical analysis
The unit of analysis in this paper is the occlusal surface of the
first permanent molar (6 tooth surfaces per student: the 4
mesial and distal pits of the occlusal surfaces of the maxillary
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1585
Definition
After cleaning and drying the tooth, the examiner visually checked whether
the tooth surface was cavitated (loss of enamel). If not, and if the pits and fissures
were colored light or dark brown at base and/or a white change
(demineralization) in sides of the pits or fissures was detected, then the area was
scored as non-cavitated. Stained pits and fissures were also coded in this category.
A "cavity" is defined as any loss of tissue beyond the boundaries of
developmental pits and fissures on occlusal surfaces . Cavities were defined into
arrested lesions that do not have softened floors or sides that can be detected using
an explorer with gentle pressure. Active cavitated lesions contain demineralized
dentin (usually light brown) and have soft texture when explored with gentle
pressure.
first permanent molars and the 2 occlusal surfaces of the
mandibular first permanent molars). The descriptive data
showed that multiple sealants were found in each student with
sealants. Therefore, sealant placement, as an event, was
dependent on the characteristics of the student. We have
observed that the presence of 1 sealant in a mouth makes the
occurrence of another sealant more likely. In other words,
there is a clustering effect similar to the one encountered in
clustered sample designs or longitudinal clinical trials.
Consequently, the estimated variance, assuming that the
event-in this case new sealant placement or the change of
status in a sealant over the two years of follow-up-is
independent, could result in erroneous conclusions. The
variance should be computed with an adjustment for the
clustering effect. The correction factor, which takes into
account subject dependencies, is called the design effect (deff).
A simple method for its calculation is given by the Rao and
Scott (1992) procedure, which could be used to estimate an
"effective" sample size that is used to compute an adjusted
variance and design effect. The effective sample size is the
total sample size (number of occlusal surfaces of first
permanent molars for all students) reduced by the value of the
design effect.
According to their method, for m children, there are xi
sealants on ni occlusal surfaces for student i. An estimator for P,
the proportion of sealed occlusal surfaces, is x/N, where x and N
are the sums of xi and ni for i = 1, m (students 1 through m).
That is, x is the total number of sealants and N is the total
number of occlusal surfaces for the m children, and P is the
fraction of sealed surfaces and also the probability that a surface
selected randomly from a student chosen at random will be
sealed.
The variance of P may be calculated in two ways: with and
without correction for dependencies. Without correction for
clustering effect, the binomial estimate of the variance is v(b) =
P(1-P)/N. This estimate assumes no within-subject clustering
and, if used in statistical testing, could lead to erroneous
conclusions (Type I error).
The adjusted variance is computed by the following
approach as described by Rao and Scott (1992):
First, for each student, the deviation of the observed number
of sealants from the expected number of sealants is computed
1586 Ismail & Gagnon j Dent Res 74(9) 1995
Table 3. Percentage distribution of sound, non-cavitated carious, filled, or sealed occlusal surfaces of first permanent molars (6 surfaces) in
1990 by status in 1992a
Status in 1992
Status in 1990 N Sound Filled Fully sealed Partially sealed Sealed NC NC C Missing
Sound 2534 43.7 10.9 13.3 1.5 1.3 28.3 1.2
Non-cavitated (NC) 330 0.3 34.6 6.5 0.2 3.9 51.0 3.4
Cavitated (C) 65 64.1 1.2 18.9 11.5 4.3
Filled 400 0.2 98.7 0.7 0.2 0.2
Fully sealed 600 3.9 2.7 73.5 4.5 9.9 5.0 0.1
Partially sealed 35 16.5 2.6 18.5 19.1 10.5 32.7
a Refer to the "Results" section for findings of statistical
testing.

by the following formula: A FORTRAN program was written to compute the test
statistic and incorporates sampling weights. In addition, the
ri = xi - (ni * P), for student i SPIDA (Statistical Package for Interactive Data Analysis:
MacQuire University, New South Wales, Australia) statistical
The adjusted variance of P is v estimated by the ri deviations: programs were used to compute logistic regression coefficients
by the Generalized Estimating Equations (GEE) method for
m analysis of dependent observations (Liang and Zeger, 1986;
m* r Zeger et al., 1988). The probability of failure of a sealant and the
i=l probability of sealant placement on the occlusal surfaces of the
V
(m-1) *
N2 first permanent molars were modeled separately against the
following risk indicators: age of child in 1990; caries-free status
The ratio of v to v(b), called the design effect (deff), is: in 1990; gender of the dentist who provided the restorations or
who last saw the child for a regular check-up; restorative profile
deff - N*v of the dentist in the insurance database; regularity of dental
M(-P) visits during the two years before the baseline examination. The
highest education level in the household and socio-economic
Therefore, the effective sample size that is used in adjusting the indicator (SEI) of the area where the school is located were
variance v(b) for clustering effect is: defined by the Conseil scolaire de l'ile de Montreal, based upon
the poverty index of the school area and the number of children
N in the school.
n =-~
deff
Results
This computation of the effective sample size allows the analyst Out of the 733 children with complete data, 54 (7.4%) did
to test easily for differences among proportions using standard not visit a dentist during the two years of follow-up, and 344
statistical formulae. (47.2%) visited a dentist but did not receive restorative
For example, if the two groups to be compared have N1 and treatment. During the first and second years of follow-up,
N2 occlusal surfaces from ml and m2 students, then we can the proportions of children who had new sealants placed on
compute a deff for each of the groups, yielding deffl and deff2. first permanent molars were 11.6% and 17.5%, respectively.
Thus, the effective sample sizes are: A total of 600 tooth surfaces of first permanent molars
was fully sealed in 1990, and 35 were partially sealed. After
two years, 73.5% of all fully sealed first permanent molars in
and n22 = N2
N N1 N
n
deff deff2 1990 were diagnosed as fully sealed, and 4.5% were partially
sealed (Table 3). Of the fully sealed first permanent molars,
If the proportions are P1 and P2, then the Z test for the equality 9.9% were diagnosed with non-cavitated carious margins. A
of these proportions is: significantly higher proportion of partially sealed first
permanent molars compared with fully sealed ones was
Pi - P2 diagnosed with non-cavitated caries after two years of
z =- --where Q1 = 1 - P1 and Q2 = 1 - P2 follow-up (P = 0.007) (Table 3). Sealed first permanent
(p *
Q1) + (W2 Q2) *
molars had a significantly lower proportion of tooth surfaces
ni n2 (14.9%) diagnosed with non-cavitated caries after two years
(P < 0.0001), compared with sound (and unsealed) first
permanent molars (29.6%). Compared with sound and non-
Since deff is usually greater than unity, its effect is to produce larger cavitated first permanent molars in 1990, fully sealed first
adjusted standard errors, and thus wider confidence intervals, which permanent molars had 75% and 92% lower incidence of new
reduces the probability of a Type I error being made. restorations, respectively.
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j Dent Res 74(9) 1995 Sealants in Dental Practices 1587

Table 4. Total number of sound, non-cavitated, and sealed occlusal restorative visit, 74.9% remained sealed (Table 5).
surfaces of first permanent molars and the percentage (in A total of 507 new sealants and 428 new restorations was
parentheses) restored with a Class I restoration after two years of placed on first permanent molars during the two years of
follow-up by parent's highest education status follow-up. Over 80% of the new sealants were placed on
Parent's highest education status sound first permanent molars (Fig. 1). Children from
Status in 1990 Elementary High School College University households where the highest education status attained was
from a university or college or who lived in areas with a
Sound 201 (8.4) 772 (12.9) 603 (12.3) 805 (7.2) high socio-economic indicator had a significantly higher
Non-cavitated (NC) 80 (29.3) 114 (36.9) 73 (30.8) 56 (17.1) proportion of new sealants than children from households
Sealed 31 (18.4) 144 (1.9) 24 (1.8) 7 (0.6) where the highest education was high or elementary school
only (Fig. 2) or who lived in areas with a low socio-economic
P-valuesa indicator (Fig. 3). About 45% of the new sealants placed
Sound vs. NCb NSb 0.003 NS NS during the two years of follow-up were identified in
Sound vs. sealed NS <0.0001 0.003 0.0002 children whose parents had a university education.
NC vs. sealed NS <0.0001 0.002 0.008 In the logistic regression model (GEE), the only
significant risk marker associated with placement of new
a
Statistical testing was conducted according to the Rao and Scott sealants was the education status of the household (students
method (1992).
b NC = Non-cavitated; NS = Not significant. from households with college- or university-educated
parents were more likely to get sealants) (Table 6). The
socio-economic indicator of the area where the school was
Non-cavitated carious first permanent molars were located was a significant marker for new sealant placement.
significantly less likely to be sealed than sound first The odds of sealed first permanent molars in 1990 being
permanent molars (P = 0.0009), and they were about three diagnosed after two years as either carious or restored were
times more likely to be filled (p = 0.007) (Table 3). In significantly higher in students whose parents had only
children whose parents had completed high school, college, elementary school education (Table 7). Fully sealed first
or university education, sealed first permanent molars had a permanent molars were more likely to succeed compared
significantly lower proportion of Class I restorations placed with partially sealed first permanent molars; however,
after two years (P < 0.0001) compared with sound and non- because of the small number of partially sealed first
cavitated first permanent molars (Table 4). permanent molars (n = 35), this factor did not achieve
Non-cavitated carious occlusal surfaces of first statistical significance.
permanent molars diagnosed in 1990 in children with a
restorative dental visit during the two years of follow-up Discussion
had a significantly higher probability of being restored There are two important findings in this study: the
compared with sealed occlusal surfaces (P < 0.0001) (Table effectiveness of sealants applied by private practitioners and
5). Of sealed first permanent molars in children who had the inequities in the provision of sealants to children in
only check-up visits during the two years of the study, Quebec. Before discussing these points, we will discuss the
91.8% remained sealed, whereas in children who had a weaknesses and strengths of the study.

Table 5. Percentage frequency of non-cavitated carious or sealed first permanent molars in children by dental visit based upon the Insurance
Board database, 1990-1992
Status in 1992
Status in 1990 N Sound Filled Sealed Non-cavitated Cavitated
No dental visits:
Non-cavitated 58 0.0 3.2a 4.7 84.3 7.8
Sealed 104 1.6 0.9a 90.0 7.5 0.0
P-value 0.18 0.36 < 0.0001 < 0.0001 0.06

Check-up visits only:

Non-cavitated 47 2.2 0.0 36.8 59.4 1.6
Sealed 324 3.6 0.6a 91.8 4.0 0.0
P-value 0.58 0.31 < 0.0001 < 0.0001 0.33
Restorative visits:
Non-cavitated 226 0.0 49.9 6.7 40.8 2.6
Sealed 207 7.7 7.0 74.9 10.0 0.4
P-value 0.006 < 0.0001 < 0.0001 < 0.0001 0.12
a
Those restorations were not reported to the Dental Insurance Board or they were provided in a university dental clinic.
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 1588 Ismail & Gagnon I Dciit Rcs 74(9) 1995

Status in 1990 El New sealants 90-92

University (n = 1,353) 15.9
;
12 1
Unerupted -9.8 * New sealants 90-91 (4)
0.6 College (n = 974) 14.8
Filled 0.3
(3)

Cavitated High School (n= 1,330) 7.5 Significant comparisons:

(2) 1 vs 4: P < 0.001
6.9 1 vs 3: P = 0.003
Non-cavitated 2 vs 4: P < 0.05
Primary only (n = 426)
(1)
Sound g0.2
I.
II
.. .
1
82.9 0 2 4 6 8 10 12 14 16
% New Sealants
0 10 20 30 40 50 60 70 80 90
% New sealants Figure 2. Percentage distribution of new sealants placed during the
two years of follow-up in first permanent molars by highest
Figure 1. Percentage distribution of new sealants in first permanent education status of the household.
molars by tooth status in 1990.

This study of the effectiveness of sealants is not a clinical
trial with a highly controlled environment. While this may
be a weakness, it is also a very important strength. Dentists
have been reluctant to use sealants in private practices, and
this study clearly shows that their use, under uncontrolled
conditions, is highly beneficial. The epidemiological
examiners were not aware of the tooth status in the previous
examinations, and neither the location nor name of the
dental practice where the sealants were placed was known
to the research team. Sealants were evaluated as a part of the
evaluation of dental caries and restoration quality; hence,
from the point of view of the epidemiological examiner, the
evaluation of sealants was not the main parameter in this
study. Moreover, the majority of the dentists in Montreal
were not aware of the project, though some may have
discovered its existence from parents of the sampled
children or from a local neighborhood newspaper article
which was published when the project started. Therefore,
this evaluation was carried out under "quasi-blind"
conditions.
For ethical and legal reasons, the names of the dentists
who provided the sealants are not known to the research
team; therefore, no follow-up survey of the dentists can be
I
High SE[ (1,900) 17.1
(3)
I1
Mid SEI (1,122) 9.5
Significant comparisons:
(2)
I1 1 vs 2: P <0.05
1 vs 3: P <0.0001
Low SEI (1,293)
(1) f lower proportions of Class I amalgam restorations than
0 2 4 6 8 10 12 14 16 18
% New sealants
Figure 3. Percentage distribution of new sealants placed in first
permanent molars by socio-economic indicator (SEI) of the school
area, as defined by the Conseil scolaire de l'ile de Montreal based
upon the poverty index of the school area and the number of
sealants in the school.
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carried out. The types of materials used in this study are also
not known, but it is assumed that most of the dentists used
light-activated sealants (third-generationi). The final limitation
of this study is its short duration. In spite of these limitations,
this study, for the first time in North America, provides
information on sealant performance in private practices.
Based upon findings from clinical trials and public
health programs, sealants are efficacious and effective in
preventing caries in pits and fissures (Horowitz et al., 1977;
Calderone and Davis, 1983; Mertz-Fairhurst et (?l., 1984;
Ismail et al., 1989; Romcke ct al., 1990; Simonsen, 1991).
There is evidence in North America that sealants are now
used more frequently by practicing dentists than a decade
ago (Rozier et al., 1994). The findings of this study replicate
those recently reported by Chestnutt ft al. (1994), where
7,011 sealants applied by private practitioners were
followed between 1988 and 1992 in Lanarkshire, Scotland.
After four years of follow-up, 73.7% of the sealed tooth
surfaces remained fully sealed, and 18.2% were diagnosed
as deficient sealants. Of the sound tooth surfaces in 1988,
21.4% were found decayed, filled, or extracted in 1992,
compared with only 14.4% of the fully sealed tooth surfaces
(P < 0.001), and 22.9% of the deficient sealants. Deficient
sealants were not effective in preventing dental caries.
The findings from this pragmatic longitudinal study
confirm that sealants are as effective in caries prevention
under uncontrolled conditions as they are under
experimental ones. Fully sealed occlusal surfaces of first
permanent molars had 75% and 92k lower incidences of
new restorations, compared with sound and non-cavitated
carious occlusal surfaces, respectively. While this finding
may be confounded by the education and income status of
the parents, the data presented in Table 4 show that even
when stratified by the parent's highest education status,
sealed first permanent molars had 85.3%, 85.4%, and 91.7%
sound occlusal surfaces of first permanent molars in
children whose parents had high school, college, or
university education, respectively. Compared with non-
cavitated carious first permanent molars in 1990, sealed first
permanent molars were highly protected from dental caries.
Not all types of sealed occlusal surfaces are protected
from dental caries. Partially sealed occlusal surfaces of first
J Dent Res 74(9) 1995 Sealants in Dental Practices
Table 6. Risk markers of the probability of new sealant placement
during the two years of follow-up (findings from the GEEa model)
Variable Coefficient Odds Ratios (95% CI)
Age of child -0.16 0.85 (0.65, 1.12)
Caries-free in 1990 0.14 1.15 (0.67, 1.97)
Gender of dentist 0.20 1.23 (0.78, 1.93)
% Restorative acts -0.01 0.99 (0.98, 1.00)
Not sound in 1990 -0.02 0.98 (0.75, 1.27)
Cavitated in 1990 -0.53 0.59 (0.23, 1.49)
Regular visits 0.25 1.29 (0.77, 2.16)
High school education 0.91 2.48 (0.57, 10.80)
College education 1.84 6.32 (1.50, 27.53)b
University education 1.50 4.49 (1.04, 19.30)c
a
GEE = General Estimating Equations' logistic function.
b Compared with students whose parents had elementary school
education only, P = 0.014.
c Compared with students whose parents had elementary school
education only, P = 0.044.
permanent molars were at a higher risk of developing non-
cavitated carious lesions compared with fully sealed
surfaces. There was no difference in the proportion of sound
and partially sealed first permanent molars which
developed non-cavitated caries after two years of follow-up.
These findings indicate that partially sealing a pit or fissure
may protect it from further restoration or cavitation, but
there is a higher chance of developing a non-cavitated
carious lesion. In this study, the exact location of the non-
cavitated carious lesion was not identified, and the
development of dental caries could occur in the unsealed
area or at the margin of the sealant.
Sealants were also highly effective in preventing
restorations in children who had received a restorative
service during the two years of follow-up. Almost 50% of the
non-cavitated carious occlusal surfaces of first permanent
molars were restored in children who had a restorative visit
reported to the insurance board during the two years,
compared with 7.0% of the sealed occlusal surfaces being
restored during the same period of follow-up. Sealants also
protected the occlusal surfaces from developing staining or
non-cavitated caries during the two years.
In the sample of children in this study, a higher number
of sealants was placed on the occlusal surfaces of first
permanent molars than restorations. This finding contradicts
many of the previous observations about the reluctance of
dentists to use sealants and may also indicate that caries
incidence today is too low to sustain a restorative-oriented
practice.
This study also shows that there were inequities in
sealants' availability. Caries-free children and children
from university-educated families were more likely to get
sealants. Children whose parents had university education
received almost half of all the applied sealants. These
findings raise many questions about the equity in the
dental insurance program, in Quebec and other Canadian
provinces, which pays for restorative care only, and
consequently, children from low- or middle-income
families who cannot afford the extra cost of sealants
receive restorations only. All health programs must be
Downloaded from http://jdr.sagepub.com at UNIVERSIDAD DE CARTAGENA on July 15, 2010
1589
Table 7. Risk markers of the probability of sealant failurea during
the two years of follow-up (findings from the GEEb model)
Variable Coefficient Odds Ratios (95% CI)
Age of child -0.25 0.78 (0.48, 1.28)
Caries-free in 1990 -0.63 0.53 (0.17,1.63)
Gender of dentist 0.49 1.63 (0.60,4.40)
% Restorative acts -0.01 0.99 (0.95,1.02)
Regular visits -0.001 1.00 (0.35, 5.44)
Full/partial -6.00 0.002 (0.00, 5.44)c
High school education -2.06 0.13 (0.51, 0.32)d
College education -1.44 0.24 (0.11, 0.53)d
University education -2.02 0.13 (0.06, 0.28)d
a Sealant failure = non-cavitated or cavitated or restored after the
baseline examination.
bGEE = General Estimating Equations' logistic function.
c p = 0.126.
d Compared with students whose parents had elementary school
education only, P < 0.0001.
dynamic: In this case, the services covered have not
changed, even though the disease incidence, severity, and
distribution in the children have changed significantly
since 1974, when the insurance program was implemented
in Quebec.
Over 80% of the sealants were applied on sound occlusal
surfaces. Non-cavitated and stained pits and fissures were
less likely to be sealed. There is evidence that early carious
lesions, if successfully sealed, could be arrested
(Handelman, 1991), and the recent 10-year data from a
clinical trial indicate that even caries in dentin could be
sealed effectively (Briley et al., 1994). While this is still an
experimental procedure and the indications are not
thoroughly researched, the concept of using sealants in
caries management as well as in prevention must be
investigated. In fact, given the current low caries prevalence
in occlusal surfaces, sealing all teeth may not be cost-
effective. Therefore, sealing pits and fissures with
"questionable" caries or non-cavitated/stained caries may
be more cost-effective. Further confirmatory data of this
assumption are needed.
In conclusion, this pragmatic longitudinal study has
shown that sealants were effective in preventing dental
caries and restorations when applied in private practices.
Partially sealed occlusal surfaces of first permanent molars
were at a higher risk of developing non-cavitated caries
compared with fully sealed ones. Sealants were applied
inequitably, with children from highly educated families,
and low caries prevalence, receiving the majority of new
sealants.
Acknowledgments
The authors gratefully acknowledge Dr. Jean-Marc Brodeur,
Dr. Daniel Picard, Dr. Talia Hamalian, Dr. Marie Olivier, Dr.
Martin Payette, Mr. James Warren, and Ms. Sylvie
Williamson for their work in this project, and Dr. Chris
Field, Department of Mathematics and Statistics, Dalhousie
University, for his review of the statistical methods used in
this paper. This investigation was supported by NHRDP
1590 Ismail & Gagnon
grant number 6605-1340-CD from Health and Welfare,
Canada.
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