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Rapid scoping review
A report based on Living OVerview of Evidence by Epistemonikos
PIT AND FISSURE SEALANTS VERSUS FLUORIDE VARNISH FOR PREVENTINGAND ARRESTING OCCLUSAL CARIES.
November 27th, 2019
Rapid scoping review November 27th, 2019
Pit and fissure sealants versus fluoride varnish for preventing and arresting occlusal caries.
EXECUTIVE SUMMARY We identified four systematic reviews relevant to the question of interest, including eight primary studies overall, all of them corresponding to randomized trials. Additionally, we identified three trials not included in any systematic review, and two ongoing trials. We concluded that any systematic review includes all of the available trials, but there is one that outperforms the rest in terms of comprehensiveness. However, the results of the missing trials might have substantial impact on the conclusions of a new evidence synthesis.
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Pit and fissure sealants versus fluoride varnishes for occlusal caries
Evidence report - 2019
BACKGROUND A current and well conducted systematic review is considered the best research evidence. Tens of thousands of systematic reviews are conducted each year, and the number is increasing, so most of the time multiple reviews will be available to answer a specific question. The L·OVE platform provides easy access to all the reviews relevant for a given question, taken from Epistemonikos database, the largest database of systematic reviews in health. However, additional insight is needed to determine which review, if any, is optimal to inform health decisions.
OBJECTIVE This report aims to identify the relevant evidence, and to provide guidance about the appropriateness of the available systematic reviews for decision-making on the question of interest.
METHODS This is an abridged version of the methods used to generate this report. For more details see appendix 1.
● Identification of the evidence: ○ We used a previously validated search strategy to retrieve all of the
systematic reviews available in Epistemonikos database (built by regularly screening 10 databases).
○ We looked for additional randomized trials not included in reviews by searching Pubmed and the WHO International Clinical Trials Registry Platform, and by tracking any unpublished or ongoing trial mentioned in the reviews.
○ We searched in other sources, such as the references of the included articles and the forward and backward citation tracking of relevant articles.
○ For details about the search strategies see appendix 2.
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Evidence report - 2019
● Selection of the evidence: ○ At least two researchers evaluated the abstract and full text of potentially
eligible articles. ○ We included all the articles fulfilling our inclusion criteria (see below).
Discrepancies were resolved by consensus.
● Analysis of the evidence: ○ We built a matrix of evidence to compare the systematic reviews and
their included studies, and we explored the reasons for a study not being included in a specific review.
○ We analysed the appropriateness of each review in terms of currency and comprehensiveness, and certainty of the evidence.
Inclusion criteria
Type of evidence
Systematic reviews, studies of any design included in those reviews, and randomized trials not included in reviews
Population ● Participants of any age ● Type of teeth: Primary and permanent molars ● Type of lesion: Cavitated and non-cavitated caries lesions, and
sound dental hard tissue. ● Location: Coronal ● Tooth surface: Occlusal
Intervention Pit and fissure sealants ● We included any sealant material.
Comparison Fluoride varnish ● We included all fluoride varnish concentrations.
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RESULTS
Systematic reviews From 10 potentially eligible systematic reviews, 10 were relevant based on the title and abstract (see PRISMA Flow Diagram in appendix 3). After checking the full text, we identified four that addressed all the components of the question of interest reviews. Six were excluded because they did not provide an effect estimate for the comparison of interest (Appendix 4).
List of included reviews
Review Reference
Urquhart 2019 Urquhart O, Tampi MP, Pilcher L, Slayton RL, Araujo MWB, Fontana M, Guzmán-Armstrong S, Nascimento MM, Nový BB, Tinanoff N, Weyant RJ, Wolff MS, Young DA, Zero DT, Brignardello-Petersen R, Banfield L, Parikh A, Joshi G, Carrasco-Labra A. Nonrestorative Treatments for Caries: Systematic Review and Network Meta-analysis. Journal of dental research. 2019;98(1):22034518800014.
Ahovuo-Saloranta 2016
Ahovuo-Saloranta A, Forss H, Hiiri A, Nordblad A, Mäkelä M. Pit and fissure sealants versus fluoride varnishes for preventing dental decay in the permanent teeth of children and adolescents. Cochrane Database of Systematic Reviews. 2016;1(1):CD003067.
Wright 2016 Wright JT, Tampi MP, Graham L, Estrich C, Crall JJ, Fontana M, Gillette EJ, Nový BB, Dhar V, Donly K, Hewlett ER, Quinonez RB, Chaffin J, Crespin M, Iafolla T, Siegal MD, Carrasco-Labra A. Sealants for Preventing and Arresting Pit-and-fissure Occlusal Caries in Primary and Permanent Molars. Pediatric dentistry. 2016;38(4):282-308.
Schwendicke 2015 Schwendicke F, Jäger AM, Paris S, Hsu LY, Tu YK. Treating Pit-and-Fissure Caries: A Systematic Review and Network Meta-analysis. Journal of dental research. 2015;94(4):522-33.
Primary studies Studies included in reviews The systematic reviews included eight relevant randomized controlled trials overall, reported in 12 references. Appendix 5 contains the list of trials that were excluded and the reasons. Studies not included in reviews The search in PubMed yielded 128 citations. After the first screening, 10 articles were selected and the full text were retrieved. Two reviewers assessed the full publications, and ultimately a total of 4 papers that reported 2 randomized trials were included. Finally, WHO International Clinical Trials Registry search allowed identified 1 randomized trial already published and two ongoing clinical trials.
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Evidence report - 2019
List of randomized trials included in systematic reviews Study name Long name/official title
Randomized trials included in systematic reviews
Salem et al. Salem et al [provisional name] IRCT 138802091861 See associated publications in Epistemonikos
Liu et al. Liu et al (The University of Hong Kong) [provisional name] NCT01446107 See associated publications in Epistemonikos
Tagliaferro et al.
Tagliaferro et al [provisional name] See associated publications in Epistemonikos
Ji et al. Ji et al [provisional name] See associated publications in Epistemonikos
Bravo et al. Bravo et al [provisional name] See associated publications in Epistemonikos
Fiório et al. Flório et al. [provisional name] See associated publication in Epistemonikos
Raadal et al.
Raadal et al [provisional name] See associated publication in Epistemonikos
Houpt et al. Houpt et al [provisional name] See associated publication in Epistemonikos
Randomized trials not included in systematic reviews
SoV SoV trial ISRCTN17029222 See associated publication in Epistemonikos
Rossi et al. Rossi et al. [provisional name] ISRCTN81071356 See associated publication in Epistemonikos
Kalnina et al. Kalnina et al. [provisional name] See associated publication in Epistemonikos
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Evidence report - 2019
Ongoing trials NCT03315312
Title FISSURE-Project. Improved Dental Decay Management in Dental Service for Children: Fissure Sealants or Fluoride Varnish?
Responsible party Oral Health Centre of Expertise in Eastern Norway
Study start date February 1, 2017
Estimated Study Completion Date
December 31, 2022
CTRI/2018/05/013799
Title Evaluation of relative effectiveness of fissure sealants and fluoride varnish in prevention of occlusal caries in children A Randomized Control Trial
Responsible party Vishnu Dental College
Study start date January 2, 2018
Estimated Study Completion Date
No information
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Evidence report - 2019
Analysis of the evidence Through the analysis of the matrix of evidence, it is observed that none of the systematic reviews included all of the trials identified. Among the reviews, the largest proportion of relevant trials (7 out of 11) is included in Ahovuo-Saloranta 2016. The reason why three relevant trials are not included in Ahovuo-Saloranta 2016 are the following:
● Two trials (SoV trial, Kalnina et al.) were published after the search date of the review,
● One trial was identified by the review only as a protocol version (Rossi et al.) Regarding the impact that the missing trials would have in the conclusions, it is reasonable to anticipate a substantial modification on the effect estimates, considering the total number of patients randomized in the missing trials is more than 1.400. See the comparison between reviews and studies in figure 1.
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Evidence report - 2019
Figure 1. Comparative table of systematic reviews and included primary studies
SoV trial
Kalnina et al.
Rossi et al.
Salem et al.
Liu et al.
Tagliaferro et al.
Ji et al.
Bravo et al
Flório et al.
Raadal et al.
Houpt et al.
Urquhart 2019
Wright 2016
**
Ahovuo- Saloranta 2016
Schwendicke 2015
The coloured cells represent studies included by a specific systematic review The reasons why a study is not included in a review is represented by the following symbols
The study was published after the search conducted by the review
The study was excluded because they did not fulfill inclusion criteria (Study design, Population, Intervention, Comparison, Outcome or Other(•)).
The study was probably missed by the review (not mentioned as an included or excluded study, and not possible to explain by another reason)
*The systematic review included information from this trial, but it might not be the most updated information available, See an online version of the Matrix of Evidence in Epistemonikos database Pit and fissure sealants versus fluoride varnish for preventing and arresting occlusal caries
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Evidence report - 2019
Considerations about this report Is a new evidence synthesis needed? Considering the existence of three completed trials and two ongoing trials evaluating the question of interest, a new systematic review is very likely to change the estimate. Does the best available evidence allow to make a reliable decision? In case a decision must be taken with the available evidence, there is a systematic review that outperforms the rest in terms of comprehensiveness and currency (Ahovuo-Saloranta 2016). However, it is important to bear in mind that there is uncertainty associated with this decision because the review does not incorporate a substantial proportion of the evidence from randomized trials available for this question.
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Appendix 1. Methods We considered systematic reviews summarizing primary studies (randomised and non-randomised studies) in accordance with definition by the Cochrane Collaboration and the PRISMA Statement: ‘A systematic review attempts to collate all empirical evidence that fits pre-specified eligibility criteria to answer a specific research question. It uses explicit, systematic methods that are selected with a view to minimizing bias, thus providing reliable findings from which conclusions can be drawn and decisions made’. Type of reviews An eligible review needs to fulfill all of the following operational criteria:
● Reports searching in at least one electronic database ● Reports at least one criterion for the inclusion of studies
Type of participants We include reviews summarizing studies on the topic of this L·OVE in human participants. Types of outcomes We include reviews presenting a synthesis (quantitative or qualitative) of at least one patient reported outcome or other information relevant for population or individual health decisions. Search strategy Electronic searches We conduct searches in Epistemonikos, a comprehensive database of systematic reviews relevant for health decision-making. Epistemonikos is maintained by screening multiple information sources to identify systematic reviews and their included primary studies, including the Cochrane Database of Systematic Reviews, Pubmed/MEDLINE, EMBASE, CINAHL, PsycINFO, LILACS, DARE, HTA Database, Campbell database, JBI Database of Systematic Reviews and Implementation Reports, EPPI-Centre Evidence Library. We do not apply language or publication status restrictions. The following strategy is used to search Epistemonikos: The full search strategy for this question is reported in Appendix 2. Data collection and analysis Selection of reviews At least two reviewers independently screened titles and abstracts to identify relevant articles. The full text of potentially eligible reviews were retrieved and independently evaluated for final inclusion. A senior researcher resolved disagreements.
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Appendix 2. Search strategy
Search strategy for systematic reviews Source: Epistemonikos database Date of search: 27 November, 2019
1. ((occlus*)) AND ((sealant* OR (seal*AND (pit* OR fissure* OR resin* OR compomer* OR composite* OR glass* OR cyanoacrylate* OR methacrylate* OR "BIS‐GMA" OR dimethacrylate* OR light* OR chemical* OR cure* OR GIC* OR Giomer*)))) AND (((varnish* OR paint* OR laquer* OR lacker* OR lakk* OR coating* OR polyurethane* OR duraphat*) AND (fluor* OR ppm* OR SNF2 OR SMFP OR NH4F OR monofluor*)))
Search strategy for primary studies Source: Pubmed database Total = 128 hits [27 de Noviembre, 2019] See results in PubMed
1. carie* OR carious* OR ICDAS OR (white* AND spot*) OR ((dent* OR tooth* OR teeth* OR root* OR enamel* OR cervical*) AND (cavit* OR decay* OR fissure* OR decalcificat* OR microcavit* OR noncavitated* OR "non-cavitated" OR "non cavitated" OR precavitated* OR "pre-cavitated" OR "pre cavitated" OR demineralizat* OR demineralisat* OR hypermineralizat* OR hypermineralisat* OR remineralizat* OR remineralisat*))
2. sealant* OR (seal* AND (pit OR fissure* OR resin* OR compomer* OR composite* OR glass* OR cyanoacrylate* OR methacrylate* OR "BIS‐GMA" OR dimethacrylate* OR light* OR chemical* OR cure* OR GIC* OR Giomer*))
3. (varnish* OR paint* OR laquer* OR lacker* OR lakk* OR coating* OR polyurethane* OR
duraphat*) AND (fluor OR fluoride OR ppm* OR SNF2 OR SMFP OR NH4F OR monofluor*)
4. (randomized controlled trial [pt] OR controlled clinical trial [pt] OR randomized [tiab] OR placebo [tiab] OR drug therapy [sh] OR randomly [tiab] OR trial [tiab] OR groups [tiab]) NOT (animals [mh] NOT humans [mh])
5. #1 AND #2 AND #3 AND #4
Source: WHO International Clinical Trials Registry
1. “Fluoride varnish” 2. “Sealant” 3. #1 OR #2
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Appendix 3. PRISMA flowcharts
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Appendix 4. List of excluded systematic reviews
Reference Reason for exclusion
Azarpazhooh 2008 Azarpazhooh A, Main PA. Pit and fissure sealants in the prevention of dental caries in children and adolescents: a systematic review. Journal (Canadian Dental Association). 2008;74(2):171-7.
Does not provide an estimate of the effect (e.g. meta-analysis) for the comparison of interest
Mejàre 2003 Mejàre I, Lingström P, Petersson LG, Holm AK, Twetman S, Källestål C, Nordenram G, Lagerlöf F, Söder B, Norlund A, Axelsson S, Dahlgren H. Caries-preventive effect of fissure sealants: a systematic review. Acta odontologica Scandinavica. 2003;61(6):321-30.
Does not provide an estimate of the effect (e.g. meta-analysis) for the comparison of interest
Tellez 2013 Tellez M, Gomez J, Kaur S, Pretty IA, Ellwood R, Ismail AI. Non-surgical management methods of noncavitated carious lesions. Community dentistry and oral epidemiology. 2013;41(1):79-96.
Does not provide an estimate of the effect (e.g. meta-analysis) for the comparison of interest
Sharma 2015 Sharma G, Puranik MP, K R S. Approaches to Arresting Dental Caries: An Update. Journal of clinical and diagnostic research : JCDR. 2015;9(5):ZE08-11.
Does not provide an estimate of the effect (e.g. meta-analysis) for the comparison of interest
Rozier 2001 Rozier RG. Effectiveness of methods used by dental professionals for the primary prevention of dental caries. Journal of dental education. 2001;65(10):1063-72.
Does not provide an estimate of the effect (e.g. meta-analysis) for the comparison of interest
Twetman 2015 Twetman S, Dhar V. Evidence of Effectiveness of Current Therapies to Prevent and Treat Early Childhood Caries. Pediatric dentistry. 2015;37(3):246-53.
Does not provide an estimate of the effect (e.g. meta-analysis) for the comparison of interest
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Evidence report - 2019
Appendix 5. List of excluded primary studies Reference Reason for exclusion
Bakhshandeh 2014 Bakhshandeh A, Ekstrand K. Infiltration and sealing versus fluoride treatment of occlusal caries lesions in primary molar teeth. 2-3 years results. International journal of paediatric dentistry. 2015;25(1):43-50.
Pit and fissure sealants plus fluoride varnish versus fluoride varnish.
Honkala 2015 Honkala S, ElSalhy M, Shyama M, Al-Mutawa SA, Boodai H, Honkala E. Sealant versus Fluoride in Primary Molars of Kindergarten Children Regularly Receiving Fluoride Varnish: One-Year Randomized Clinical Trial Follow-Up. Caries research. 2015;49(4):458-66.
Pit and fissure sealants plus fluoride varnish versus fluoride varnish.
Splieth 2001 Splieth C, Förster M, Meyer G.. Additional caries protection by sealing permanent first molars compared to fluoride varnish applications in children with low caries prevalence: 2-year results. European Journal of Paediatric Dentistry. 2001;2(3):133-138.
Pit and fissure sealants plus fluoride varnish versus fluoride varnish.
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Rapid scoping review
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