The combined use of pit and fissure sealants and fluoride mouthrinsing in second and third grade children: one-year clinical results.

The combined benefits of pit and fissure sealants and weekly mouthrinsing with a 0.2% NaF solution were assessed. Second and third grade children participating in a school-based fluoride mouthrinsing program since kindergarten had an autopolymerized tinted sealant (Delton®) applied to the occlusal surfaces of all 4 cariesfree first permanent molars and to buccal pits and lingual grooves as indicated. Children in the same grades with a caries-free permanent dentition, who also were participating in the mouthrinsing program, served as a comparison group. Of 95 sealant/fluoride mouthrinsetreated children, 87 were available for examination after 1 year. Three children had a total of 3 DF surfaces. Twelve of 81 comparison subjects had 13 DF surfaces. All of the DF surfaces in both groups of children involved the pits and fissures. There were no decayed or filled proximal surfaces. The benefits of sealing and mouthrinsing are additive and the addition of sealants to a mouthrinsing program increases the number of children who continue to be caries free. However, sealing of occlusal surfaces that might not decay increases the cost of sealant application relative to the surfaces saved. In 1975 a weekly school-based fluoride mouthrinsing program using 0.2% NaF was begun in the elementary schools (grades K-6) of the Three Village Central School District, Long Island, New York (F 0.1 ppm). After 6 years, participants in the program demonstrated a 55% reduction in caries prevalence compared to children who received baseline examinations in 1975, before the program started. 1 The decline in caries prevalence, however, was not uniform for all tooth surfaces. In sixth grade children who had been rinsing since kindergarten, the highest percentage reduction, up to 83%, occurred on the smooth proximal surfaces, while pit and fissure caries of the buccal, lingual, and occlusal surfaces had caries reductions of 40-52%.2 Furthermore, 94% of the carious or filled tooth surfaces in sixth grade mouthrinse participants involved the pits and fissures, while only 6% involved smooth surfaces. Since fluoride mouthrinsing has its greatest relative caries protective benefit on the smooth tooth surfaces and sealants protect exclusively the pits and fissures, a significant additive benefit should be realized by the combined use of the 2 procedures. The concomitant use of different topical fluoride treatments and sealants has been recommended previously, 3,4 and several studies in which fluorides and sealants were used together have been reported. 5-9 Rantala described the use of a self-applied 2% NaF gel (9040 ppm F) and sealants in first to third grade Finnish school children. 5 Low treated 10to 13-year-old Malayan school children with an initial topical application of 8% SnF2 followed by sealant applications. 6 In the United States, Bagrarnian et al. conducted a schoolbased program in .an optimally fluoridated community in which biannual topical applications of APF gel and sealants were a component, 7,8 and Bell et al. conducted a 4-year program on school children in 10 different cities in which sealants were used with APF gels, fluoride mouthrinses, or dietary fluoride supplements in a combination of preventive regimens. 9 While there is a public health program involving the combined use of a fluoride mouthrinse and sealants, the effect of the combined preventive procedures on caries has not been reported. 1° The purpose of this study was to assess the addi158 SEALANTS AND FLUORIDE MOUTHRINSING: Ripa et al. tive benefits of sealants applied to caries-free first permanent molars of second and third grade school children who were participating in a school-based fluoride mouthrinsing program since kindergarten. The 1-year caries increment of fluoride mouthrinse participants was compared to that of children who were in the mouthrinsing program and had received sealants. Sealant retention also was assessed as well as the restorative treatment needs of both groups of children. The results presented are the first year findings in a continuing 2oyear study. Methods and Materials Subjects The children were participants of a school-based weekly 0.2% NaF mouthrinse program since kindergarten. They were in the mixed dentition stage with permanent incisors and first permanent molars erupted. Only children with all 4 first permanent molars present and no caries or fillings in their permanent teeth were invited to participate. At the beginning of the 1983-84 academic year, children received visual-tactile examinations for caries as part of the mouthrinsing program. The examiner used the criteria for caries established by the ADA Conference on the Clinical Testing of Cariostatic Agents.11 Of 409 second and third graders (7-8 years old) examined, 258 had caries-free permanent teeth with all 4 first permanent molars erupted. Consent to participate in the sealant program was solicited through forms mailed to parents. One hundred twenty-seven (49.2%) of the children returned positive consent forms. However, some later withdrew, failed to keep their appointments, developed carious lesions, or had dental treatment performed before their teeth were sealed. Ninety-five second and third grade children who had their 4 first permanent molars sealed are the subjects of this study. One hundred thirty-one caries-free children who were participating in the weekly fluoride mouthrinsing program but did not receive sealants constituted a comparison group with which to assess the relative benefits of the sealant/fluoride mouthrinse combination. Strictly speaking, these children do not represent a true control group since they did not agree to receive sealants, but were examined as part of the fluoride mouthrinsing program. They were identified as being caries free at the baseline examination and were examined after 12 months. The sealant-treated children participated in both examinations, but also received another examination when the sealants were placed. Any child who had developed caries or received a filling on a first permanent molar was disqualified from the study at the presealant examination. Sealant Application Sealants were placed 4 months after the baseline caries examinations. The delay was caused principally by the time needed to obtain consent and various school holidays. Treatment was accomplished by 4 fourth-year dental students at the dental clinic of the School of Dental Medicine, State University of New York at Stony Brook. The students were participating in the pedodontic elective program of the Department of Children’s Dentistry. They were experienced in the use of sealants and each had placed an average of 56 sealants before participating in this program. The autopolymerized tinted Delton ® Pit and Fissure Sealant ~ was used. The students worked in teams of 2 with 1 serving as the operator and the other as the assistant. The first permanent molars were examined by one of the principal investigators (LWR or GSL) to confirm that they were caries free. If caries was detected, a conference was held between both examiners to assure agreement. The sealant then was applied according to the manufacturer’s directions. Cotton roll isolation was used throughout. Sealant was applied to the occlusal surfaces of all 380 first permanent molars and to the buccal pits of mandibular first molars and lingual grooves of maxillary first molars when morphologically present and sufficiently erupted to be sealed. After application, all sealed surfaces were checked by one investigatok using a mirror and explorer. If sealant was not covering all pits and fissures or if it was dislodged by the explorer tip, additional sealant was applied using a 10-sec etch procedure and the sealant was reexamined before the patient was dismissed. Examinations and Analysis One year after the baseline examinations, the mouthrinseand mouthrinse/sealant-treated children received visual-tactile examinations for caries by the same examiner. At this examination, the condition of the sealant also was evaluated. Surfaces treated with sealant were recorded as completely covered, partially covered, or uncovered. It also was recorded if treatment was needed -either a restoration or sealant reapplication. A comparison was made of the 1-year caries increment between the comparison (mouthrinsing) group and the experimental (mouthrinse/sealant) group and of the treatment needs of the 2 groups. An adjustment was made in the caries increment of the mouthrinsing group to compensate for the additional 4-month examination received by the sealant-treated children. Johnson & Johnson Dental Products Co: East Windsor, NY. PEDIATRIC DENTISTRY: June 1986/Vol. 8 No. 2 159