Fluoride Varnish. Fissure Sealants. Does My Kid Need These?

Recently, I was talking with a few mums. We all have children under the age of 10yrs. We all happen to work in health-related areas. One mum mentioned her 6yo recently had fissure sealants placed on his four first permanent molars and now feels relieved that he won’t get dental cavities on these adult teeth. Another mum responded that her daughter had fissure sealants on her molars and within 3 months, all the fissure sealants needed “topping up” because her daughter grinds her teeth in her sleep. I was asked if I placed fissure sealants on my daughter’s molar teeth. To which I replied, “Katelyn’s molars have not been fissure sealed. She does get fluoride varnish 2-3 times a year though.” That led to an interesting discussion regarding what is preferable for prevention of dental cavities in children, fissure sealants or fluoride varnish? And are these really necessary?

What Does Current Scientific Evidence Suggest?

Having all studied for more years than we care to count, we dived into our mobile phones for current research papers, updates and recommendations.  Here are the key findings from our impromptu journal club: 

Conclusions from the highly respected Cochrane systematic review, published in 2016 (1), suggests that there is only a limited number of good quality studies available and analysis of these indicate that fissure sealants may be slightly more superior to fluoride varnish when it comes to preventing dental cavities but the evidence is of such a low quality that clear conclusions cannot be drawn.

Another Cochrane systematic review, published in 2013 (2), which looked at the benefit of fissure sealants alone for prevention and control of dental decay concluded that fissure sealants are primarily beneficial for children with high dental decay risks. A combined American Dental Association and American Academy of Pediatric Dentistry report (3,4) on fissure sealants also supported the benefit of fissure sealants for preventing and arresting dental decay on biting surfaces of baby and adult molar teeth.

The results of a large scale Cardiff University study comparing fluoride varnish and fissure sealants in 800 6-7 yo high dental decay risk children in UK, published in March 2017 in the Journal of Dental Research (5), concluded that semi-annual applications of fluoride varnish (5% sodium fluoride) is just as protective against dental cavities as fissure sealants.

What are Fissure Sealants?

Fissure sealants are thin layers of adhesive dental materials that are placed over the biting (occlusal) surfaces of primary or permanent molar teeth, to physically cover the hard to reach deep pits and grooves of teeth, where bacteria and food debris may accumulate and result in dental decay.

Pros

• Fissure sealants provide physical protection that stay on the tooth once placed and does not dissolve quickly.
• Fissure sealants prevent bacteria and food debris from hiding in the bottom of pits and grooves of molars where the toothbrush can’t get to.
• Fissure sealants are useful for arresting early enamel decay on the biting surfaces of molar teeth as well as preventing the decay from starting.
• Some types of fissure sealants contain fluoride and provide remineralization benefits as well as sealing the deep pits and grooves.

Cons

• Fissure sealants act as physical barriers and do not result in remineralization of tooth structures.
• Fissure sealants are placed on the biting surfaces of teeth and protect these surfaces only.
• Placement of fissure sealants require more cooperation from children than fluoride varnish.
• Fissure sealants may break off or wear over time, so regular reviews and repairs are critical.
• Fissure sealants cost more than fluoride varnish.
• Fissure sealants may not be as cost-effective for children with low dental decay risks, compared to children with high dental decay risks. For children with little risks of dental decay (meaning: no cavities, no restorations, no visible dental plaque on teeth, excellent oral hygiene and diet), fissure sealants placement may be perceived as unnecessary treatment.

What is Fluoride Varnish?

Fluoride varnish is a fluoride containing dental agent that is applied or painted onto teeth for prevention of dental decay. Fluoride varnish is formulated especially to stick onto the teeth surfaces to enable remineralization by fluoride ions over time.

According to the American Academy of Pediatric Dentistry and American Academy of Pediatrics, children as young as 6mths of age can benefit from semi-annual applications of fluoride varnish.

Originally, fluoride varnish only contains sodium fluoride e.g. Duraphat ® (5% w/v sodium fluoride = 22600ppm F ions). In recent times, many different brands and formulations of fluoride varnish have become available. Notably, calcium and phosphate containing fluoride varnishes have been marketed as having superior decay prevention and remineralization benefits. However, a recent laboratory study, published in the International Journal of Paediatric Dentistry in May 2017, suggested that the original sodium fluoride containing varnish was superior for remineralization of enamel decay compared to newer formulations containing calcium, phosphate and fluoride.

Pros

• Fluoride varnish is able to reverse early tooth decay (demineralization) and remineralize tooth structures.
• Fluoride varnish can be applied to all surfaces of teeth and so exert benefits that are not limited to just pits and fissures.
• Fluoride varnish requires less cooperation from children and is easier to apply than fissure sealants
• Fluoride varnish costs less than fissure sealants.·    

Cons    

• Fluoride varnish is recommended at 2-4 times per year.
• Fluoride varnish may not penetrate into the deep pits and grooves of at risk teeth easily.

So The Verdict?

The consensus we came to from available evidence was that both fissure sealants and fluoride varnish are useful. Whether one is preferable over the other, will vary from person to person, depending on various factors including level of dental decay risk, how deep the molar pits and grooves are, age, habits and lifestyles, etc.

In addition,

• Fissure sealants are most cost effective for children with high decay risks.
• Fissure sealants are most beneficial when placed soon after the molars erupt (usually refers to the first permanent molars, but fissure sealants can be placed on any molars and premolars).
• Fissure sealants are only effective for preventing decay that occurs on the biting surfaces of teeth. Fissure sealants does not prevent against decay affecting other surfaces of teeth.
• Children who have deep pit and fissure patterns on their molar teeth are likely to benefit more from fissure sealants, compare to those with shallow pit and fissure patterns.
• Younger children are more likely to benefit more from fluoride varnish rather than fissure sealants, in light of the different level of cooperation needed for these procedures.
• Children already at high risk of dental cavities, that is, those children who have cavities or restorations in their teeth already, are likely going to benefit from both fissure sealants and fluoride varnish among other things, as multiple strategies are needed to target the multifactorial nature of dental decay and manage the disease (remember: dental cavity is not the disease itself - a cavity is what happens when dental decay is left to progress).
• Fissure sealants and fluoride varnish cannot guarantee cavity-free. Regular and effective oral hygiene and a well-balanced tooth-friendly diet are still critical.

References

1. Ahovuo-Saloranta A, Forss H, Hiiri A, Nordblad A, Makela M. Pit and fissure sealants versus fluoride varnishes for preventing dental decay in the permanent teeth of children and adolescents. Cochrane Database Syst Rev 2016; (1): CD003067. doi: 10.1002/14651858.CD003067.pub4.
2. Ahovuo-Saloranta A, Forss H, Walsh T, Hiiri A, Nordblad A, Makela M, Worthington HV. Sealants for preventing dental decay in the permanent teeth. Cochrane Database Syst Rev 2013; (3):CD001830. doi: 10.1002/14651858.CD001830.pub4.
3. Wright JT, Tampi MP, Graham L, Estrich C, Crall JJ, Fontana M, Gillette EJ, Novy 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. A systematic review of randomized controlled trials – a report of the American Dental Association and the American Academy of Pediatric Dentistry. J Am Dent Assoc 2016; 147(8):631-645.e18. doi: 10.1016/j.adaj.2016.06.003.
4. Deery C. Clinical practice guidelines proposed the use of pit and fissure sealants to prevent and arrest noncavitated carious lesions. J Evid Based Dent Pract 2017; 17(1):48-50. doi: 10.1016/j.jebdp.2017.01.008.
5. Chestnutt IG, Playle R, Hutchings S, Morgan-Trimmer S, Fitzsimmons D, Aawar N, Angel L, Derrick S, Drew C, Hoddell C, Hood K, Humphreys I, Kirby N, Lau TM, Lisles C, Morgan MZ, Murphy S, Nuttall J, Onishchenko K, Phillips C, Pickles T, Scoble C, Townson J, Withers B, Chadwick BL. Fissure seal or fluoride varnish? A randomized trial of relative effectiveness. J Dent Res. 2017 Mar 1:22034517702094. doi: 10.1177/0022034517702094. [Epub ahead of print]
6. Mohd Said SN, Ekambaram M, Yiu CK. Effect of different fluoride varnishes on remineralization of artificial enamel carious lesions. Int J Paediatric Dent 2017; 27(3): 163-173. doi: 10.1111/ipd.12243.