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ORIGINAL ARTICLE
Year : 2022  |  Volume : 25  |  Issue : 6  |  Page : 861-884

Comparative evaluation of retention and cariostatic effect of hydrophilic and hydrophobic resin-based sealants: A systematic review and meta-analysis


1 Pediatric Dentistry Department, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
2 Pediatric Dentistry Department, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia; Department of Pedodontics and Oral Health, Faculty of Dental Medicine for Girls, Al Azhar University, Cairo, Egypt

Date of Submission04-Oct-2021
Date of Acceptance22-Mar-2022
Date of Web Publication16-Jun-2022

Correspondence Address:
Dr. H M Elkhodary
Pediatric Dentistry Department, Faculty of Dentistry, King Abdulaziz University, P.O. Box: 80209, Jeddah - 21589

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_1863_21

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   Abstract 


Background: Evidence-based information should be provided to clinicians to explain the effectiveness of hydrophilic and hydrophobic forms of resin based sealants (RBSs). Aim: To assess and evaluate the retention and cariostatic effect of hydrophilic and hydrophobic RBSs in primary and/ or permanent teeth with at least a follow-up period of 3 months. Materials and Methods: Five databases were searched up to September 2021 for randomized and non-randomized clinical trials (RCTs and non-RCTs) that evaluated the retention and cariostatic effect of hydrophilic and hydrophobic RBSs. Two authors nominated the papers, extracted data, and assessed the risk of bias. Results: By comparing the retention rate and caries incidence between groups, pooled-effect estimates of included articles were generated. After removing duplicates from the 2,810 titles found, only 1938 remained. Twelve of these were thoroughly examined. A total of 12 papers met the inclusion criteria in qualitative analysis: seven RCTs and five non-RCTs. Only ten studies were included in the meta-analysis: five RCTs and five non-RCTs. After 12 months of follow-up, no significant difference was found in the retention of hydrophilic and hydrophobic RBSs with and without a bonding agent. After 12 months of follow-up, no significant difference was found in the cariostatic effect of hydrophilic and hydrophobic RBSs. Conclusion: There was no statistically significant difference in retention and the cariostatic impact was found between hydrophilic and hydrophobic RBSs.

Keywords: Conventional, fissure sealant, moisture-tolerant, molars, success


How to cite this article:
Alharthy H, Elkhodary H M, Nahdreen A, Al Tuwirqi A, Baghlaf K. Comparative evaluation of retention and cariostatic effect of hydrophilic and hydrophobic resin-based sealants: A systematic review and meta-analysis. Niger J Clin Pract 2022;25:861-84

How to cite this URL:
Alharthy H, Elkhodary H M, Nahdreen A, Al Tuwirqi A, Baghlaf K. Comparative evaluation of retention and cariostatic effect of hydrophilic and hydrophobic resin-based sealants: A systematic review and meta-analysis. Niger J Clin Pract [serial online] 2022 [cited 2022 Jul 6];25:861-84. Available from: https://www.njcponline.com/text.asp?2022/25/6/861/347614




   Introduction Top


Pit and fissure sealants have been shown to be extremely effective at preventing occlusal cavities in both primary and permanent teeth.[1],[2],[3] Multiple studies that have been conducted over extended periods reported the success of this procedure in occlusal caries prevention.[4],[5],[6],[7],[8] The main measure of the efficacy of any sealant is retention.[9] It is well-known that properly retained sealant can isolate the susceptible fissures for a longer duration thus providing long-term prevention from occlusal caries.[10] Several factors can influence the retention of pit and fissure sealants; the type of bonded enamel, the type of surface treatment, and the amount of isolation that has been performed, depending on the type of sealant material used.[11],[12]

In terms of long-term retention, wear resistance, and degradability, resin-based sealants (RBSs) are acknowledged to be the best.[13],[14] However, isolation is one of the main problems encountered during RBSs placement, especially in partially erupted teeth and uncooperative children.[15] This problem can adversely affect the retention of these materials particularly with hydrophobic RBSs. As a result, clinicians attempted to increase sealant retention by using a hydrophilic bonding agent. Unfortunately, this did not address the problem because it added additional expense and time to the procedure, making it more technique-sensitive.[16]

Recently, the introduction of hydrophilic RBSs has been considered a promising solution to this issue. Moisture-tolerant resin-based polymers that can attach to enamel even in wet conditions were used to develop hydrophilic resin innovation.[17] The inherent ability of the hydrophilic RBSs to penetrate more deeply into the pits and fissures even in presence of moisture was able to make the application of such material more rapid and less technique-sensitive. Moreover, higher mechanical properties were also seen in the hydrophilic sealants which were attributed to the ability of the manufacturer to incorporate twice the amount of fillers contained in the conventional hydrophobic sealants without affecting the penetration ability of this material inside fissures.[14] The bioactivity of the hydrophilic RBSs is another characteristic that is particularly significant for newly erupted teeth. This characteristic was discovered to benefit newly erupted teeth by enhancing the process of post-eruptive maturation and the remineralization of deep areas in pits and fissures with initial demineralization.[18]

Several studies compared hydrophilic RBSs to conventional sealants in children and they demonstrated dialectical outcomes.[17],[19],[20],[21],[22],[23],[24],[25],[26],[27] Six studies found no significant difference between the two types[19],[20],[23],[26],[27],[28] while others found that hydrophilic sealants had a better success rate.[17],[22],[24] Two studies showed a lower retention rate of hydrophilic sealant.[21],[29]

Due to the relatively recent introduction of the hydrophilic RBSs compared to hydrophobic forms of RBSs, evidence-based information should be provided to clinicians to explain their effectiveness and clinical performance. To our knowledge, there is no systematic review that compares the retention of hydrophilic versus hydrophobic RBSs. Our systematic review aimed to address three questions: First, is the application of hydrophilic RBSs (moisture-tolerant) clinically in primary and permanent posterior teeth without bonding layer comparable to the conventional hydrophobic RBSs in terms of retention? Second, is the application of hydrophilic RBSs (moisture-tolerant) with a layer of bonding agent in primary and permanent posterior teeth similar to the conventional hydrophobic RBSs in terms of retention? Third, is the application of hydrophilic RBSs (moisture-tolerant) in primary and permanent posterior teeth comparable to the conventional hydrophobic RBSs in terms of the cariostatic effect? Thus, this systematic review aimed to evaluate and compare the retention and cariostatic effect of both hydrophilic and hydrophobic RBSs in primary and/or permanent teeth with a minimum of a 3-month follow-up period.


   Materials and Methods Top


Protocol and registration

The systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards[30] and the PRISMA declaration.[31] Since this is a systematic review and meta-analysis study, there is no need for obtaining an ethical approval from the ethics committee, but the study was registered in the International Prospective Register of Systematic Review (PROSPERO) database (CRD42020221574) on Dec. 22, 2020.

Eligibility criteria

The following patient/population, intervention, comparison, outcomes and study design (PICOS) elements were used to identify the studies for this review.[32]

Participants

Healthy children aged 5 to 15 years with sound or incipient carious primary or permanent molars are indicated for fissure sealant application.

Intervention

Application of hydrophilic or moisture-tolerant RBSs.

Comparison

The comparison group included hydrophobic (conventional) RBSs.

Outcome

The main outcome was the retention of the two types of sealants with or without a bonding layer in a follow-up period of 3 months and more. Retention was assessed through a visual and tactile examination using different criteria including Color Covering Caries Sealant Evaluation System, Modified Simonsen's criteria, complete/partial retention and complete failure, Modified Ryge's criteria, as follows: Success (intact) or Failure (partial or total loss).

The second outcome was the cariostatic effect.

Study design

For inclusion, randomized and non-randomized clinical trials (RCTs and non-RCTs) with at least two trial arms comparing the retention and/or the cariostatic effect of the moisture-tolerant “hydrophilic” and conventional “hydrophobic” RBSs in primary and/or permanent teeth with at least a 3 months follow-up period were examined. Studies that did not have an acceptable control group (hydrophobic RBSs) or did not include children, studies that did not assess retention and/or caries, studies that described secondary analysis of the primary data or studies that did not have a comparable follow-up for a sample of both arms, and studies written in a language other than English were all excluded.

Studies with any age group above 15 or below 5, and all other types of studies including retrospective studies, case control studies, prospective cohort studies, cross-sectional studies, editorial letters, pilot studies, historical reviews, literature reviews, in vitro studies, and descriptive studies, such as case reports and case series were also excluded.

Information sources and search strategy

A thorough search of five electronic databases showed up pertinent papers (PubMed, Science Direct, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and Scopus Wiley). The search was limited to English-language articles and had no time constraint regarding publication time (up to September 2021). Additionally, a hand search of reference lists from identified published work and a Google Scholar search for potential studies were eligible for inclusion. Medical Subject Headings (MeSH) keywords were utilized to build a comprehensive search query. Repeated studies were detected and deleted by using the EndNote reference manager (EndNote® version 9, Niles Software, USA). Appendix 1 shows the search strategy.

Study selection and data extraction

Two reviewers (H.A.) (A.N.) examined separately the titles and abstracts of all identified papers to see if they matched the inclusion criteria. The same reviewers independently examined the full-text papers of selected studies. A third reviewer (K.B.) handled any disagreements between the two reviewers. Regarding studies that used the same sample, the study with extra data was chosen. Two reviewers (H.A.) (H.K.) assessed the selected articles independently utilizing a defined process, and the extracted data were documented in an extraction datasheet. The extracted data included were as follows: publication year, study setting (country), size of the sample, number and type of teeth, the brand and manufacturer of hydrophilic and hydrophobic RBSs, study design, mean age of patients, number of operators, details of intervention, blinding, number of examiners, follow-up period, evaluation criteria, and the retention and cariostatic effect outcome.

The success (complete retention) or failure (partial or total loss) of the sealants was recorded. Additionally, the presence or absence of caries was also documented. The data were dichotomized as stated above if the outcomes were described by the studies on a continuous scale. In case of disagreement, either the discrepancy is resolved by discussion until reaching an agreement or by a third reviewer.

Quality assessment and bias risk assessment

To assess the risk of bias in each included RCT, two authors (H.A. and K.B.) used Cochrane's risk of bias tool.[33] The Newcastle Ottawa Scale was used to assess the methodological quality of non-RCTs.[34] The meta-analysis included studies with moderate and high methodological quality (higher than five stars). No cutoff point is recommended in this tool but it is based on previously published systematic reviews.[35],[36] In case of any discrepancy between the two authors, a discussion of the value was carried out until they reach an agreement. The level of agreement between the two authors was evaluated by kappa value. For every question in this review, articles were organized according to the design by being RCT or non-RCT to allow for data synthesis by utilization of the best available evidence.[37] The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria were then used to assess the quality of each research question.[38] Based on design restrictions, risk bias, precision, directness, and consistency of the results, the GRADE method was able to grade the overall quality of evidence. The GRADE analysis also allowed to categorize the quality of evidence as high, moderate, low, or very low. Any limitations in the quality of the study or inconsistency in the results caused a marked lowering in the quality grade of the evidence.

Data synthesis

The data from the included papers were compiled. The data was organized based on the study's design, age and number of the children, number and type of teeth, size of the sample in each group, follow-up periods, analysis instrument, evaluation criteria, retention rate, and/or caries incidence outcomes. Meta-analysis of the retention success or failure and/or cariostatic effect of the hydrophilic sealant versus hydrophobic sealant were calculated if needed.

Both quantitative and qualitative syntheses were performed if possible. Studies that compared the retention rate of the two types of sealants were presented separately from studies that compared the cariostatic effect. In the case of more than one group of hydrophobic arms in the included studies, the higher retention rate was chosen for quantitative synthesis. Analysis of the retention rate of the hydrophilic sealants versus hydrophobic sealants was calculated if needed.

Revman was used to do the meta-analysis (version 5; 1, Nordic Cochrane Centre, Cochrane collaboration, 2001). Cochran's Q-test, with a statistically significant P value of 0.1, was used to check for heterogeneity in the studies. Pooled studies were with low to moderate heterogeneity >25% to 75%. A statistically significant P value was set at 0.05. Quantitative synthesis requires a minimum of two investigations. A random-effect model was conducted in case of the presence of two or more studies with the same assessment tool. Subgrouping in the forest plots was used based on the study design of either RCT studies or non-RCT studies. The formal method of combining individual study data was odds ratios for individual studies. Sensitivity analysis was used after adding all studies and compared with the results.


   Results Top


Study selection

The results of our search were able to retrieve 2810 articles which were obtained from five different databases as follows: ScienceDirect (n = 588), PubMed (n = 226), Cochrane (n = 619), Scopus (n = 214), and ClinicalTrials.gov (n = 33). In addition, other sources were also utilized in this search including a hand search in high impact factor journals and Google Scholar. Through these additional sources, we were able to retrieve additional 1130 articles. The search was conducted in September 2021.

After the removal of the duplicate results, only 1938 articles remained. Only 12 articles met the inclusion criteria for this systematic review after the titles and summaries of all these articles were assessed for suitability. After full-text reading, all 12 articles were found to be suitable for inclusion in the qualitative synthesis. Only 10 articles' data could be pooled in the meta-analysis after they were assessed for quality [Figure 1].
Figure 1: A Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow diagram showing the number of articles identified at each stage of the search

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Study characteristics

[Table 1] summarizes the key characteristics of the studies included in the qualitative and quantitative synthesis. RCTs were found in only seven of the investigations[17],[21],[22],[23],[24],[28],[29] with a split-mouth design while blinding was done in only five studies.[21],[22],[24],[28],[29]
Table 1: Characteristics of included trials

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Regarding the type of hydrophilic sealant, ten studies utilized Embrace® WetBond sealant (Pulpdent Corporation, Watertown, Mass., USA), while only two studies[24],[29] utilized UltraSeal XT® hydro (Ultradent Products, USA). Moreover, the usage of hydrophobic sealant showed more variation in which three studies[21],[22],[28] utilized Helioseal® (Ivoclar Vivadent AG, Schaan, Liechtenstein), two studies[17],[19] utilized Delton FS (Dentsply International, York, PA), three studies[24],[25],[29] utilized Clinpro (3M ESPE, St. Paul, MN, USA), one study[23] utilized Helioseal-F (Ivoclar Vivadent AG, Schaan, Liechtenstein), one study[26] utilized Fissurit F® (Voco, Cuxhaven, Germany), and two studies used two types of hydrophobic sealants: Delton FS and Clinpro in the study by Bhat et al., 2013,[20] and Helioseal-F and Clinpro in the study by Baheti et al., 2020.[27] Three studies utilized adhesive under hydrophobic sealants.[20],[27],[28]

Mean age showed considerable variations with the lowest age found in the study by Topal and Kirzioğlu, 2019[26] which was 5–8 years and the highest age was 12–15 years.[24],[29] Sample size also differed significantly between the study groups where the largest sample size was discovered in the study by Mohanraj et al., 2019[25] (600 first permanent molars in 150 patients), and the smallest sample size was found in the study by Bhatia et al., 2012[19] (68 first permanent molars in 17 patients). The type of arch utilized in the studies (maxilla or mandible) showed that all the studies utilized both arches except for three studies that utilized only the mandible.[22],[27],[28]

The method of isolation used was the same in all studies using cotton rolls except for two studies[25],[28] that utilized a rubber dam. The materials were applied as directed by the manufacturer in all studies except in two studies[27],[28] that utilized adhesive agents under hydrophobic sealants. One study utilized simply a probe as an analysis tool,[27] while two others employed both a mirror and a probe,[19],[23] two studies did not report the analysis instrument used,[26],[28] and seven studies used visual and tactile examination method.[17],[20],[21],[22],[25],[29]

The evaluation criteria of sealants were done by using the modified Simonsen's criteria in four studies;[17],[20],[25],[26] Color, Coverage and Caries (CCC) evaluation system was used in three studies;[22],[24],[29] complete retention, partial retention, and compete failure was used in two studies;[19],[21] and modified Ryge's criteria was used in three studies.[23],[27],[28] The follow-up period also showed a significant difference between the studies with Ratnaditya et al., 2015[17] having the longest (24 months) and Prabakar et al., 2018[24] having the shortest (3 months).

Quality and risk of bias

The seven RCTs that were included for Cochrane's risk of bias assessment were assessed by two authors. The inter-rater agreement for the evaluation of the risk of bias was very good (Kappa score = 87). Two of these studies were found to have a high risk of bias,[17],[23] while five were found to have a low risk of bias.[21],[22],[24],[28],[29] Regarding the types of biases, the lowest risk of bias seen was for selective reporting where all studies showed a low risk of bias in this section. On the other hand, random sequence generation was unclear in all of the included trials [Figure 2].
Figure 2: Cochrane's risk of bias assessment summary for randomized clinical trials

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The Newcastle Ottawa Scale was used by the same authors to assess the risk of bias in the five non-RCTs that were included. The inter-rater agreement for the evaluation of the risk of bias was very good (Kappa score = 84.3). Four studies[19],[20],[26],[27] were rated as having a good overall score and one was fair[25] [Figure 3].
Figure 3: Newcastle Ottawa Scale scores for non-randomized studies

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Assessment of the body of the evidence by GRADE

The GRADE rating for each research question was determined by the type of the studies either RCTs or non-RCTs. To answer the three review questions, 11 GRADE profile tables were created [Appendix 2].

Retention of hydrophilic and hydrophobic RBSs without bonding agent

RCTs with 3 months follow-up

Two RCTs[22],[24] provided the best available evidence on the retention of hydrophilic and hydrophobic RBSs without bonding agents in permanent posterior teeth of children after 3 months follow-up period. The quality of evidence was “moderate” [Appendix 2 Table S1]. The rationale for the quality downgrading was because of the indirectness, which would lessen their influence as both trials were conducted in a single country, which is India.

Non-RCTs with 3 months follow-up

Two non-RCTs[19],[25] investigated the retention of hydrophilic and hydrophobic RBSs without a bonding agent after 3 months follow-up period. The quality of evidence was deemed “low” because of its indirectness and plausible confounder [Appendix 2 Table S2]. The indirectness of these studies was downgraded as all of them were conducted in a single country (India). Furthermore, Mohanraj et al., 2019[25] did not include conditions in the study design that could affect sealant retention and function as confounding factors, such as diet type, masticatory pressures, and dental hygiene practice which downgraded the plausible confounder.

RCTs with 6 months follow-up

Two RCTs[22],[29] investigated the retention of hydrophilic and hydrophobic RBSs without a bonding agent after 6 months follow-up period. The evidence was of poor quality [Appendix 2 Table S3]. The inconsistency of results and indirectness were the reasons for the quality downgrade that would reduce their effectiveness as both trials were conducted in a single country, which is India.

Non-RCTs with 6 months follow-up

Three non-RCTs[19],[20],[25] investigated the retention of hydrophilic and hydrophobic RBSs without a bonding agent after 6 months follow-up period. Due to inconsistency, indirectness, and plausible confounders, the quality of evidence was determined to be “extremely low” [Appendix 2 Table S4]. When pooling the included studies together, inconsistency between their results was found as all studies favored the hydrophobic group except Bhat et al., 2013[20] who favored the hydrophilic group. The indirectness of these studies was downgraded as all of them were conducted in a single country (India). Furthermore, Mohanraj et al., 2019[25] did not include conditions that could potentially affect sealant retention in the study design as confounding factors, such as food type, masticatory pressures, and dental hygiene practice, which downgraded the plausible confounder.

RCTs with 12 months follow-up

Two RCTs[21],[22] investigated the retention of hydrophilic and hydrophobic RBSs without a bonding agent after 12 months follow-up period. The quality of evidence was also found to be “moderate” due to their inconsistency, which would reduce their effect [Appendix 2 Table S5]. The findings from Khatri et al., 2015[22] showed a statistically significant difference with more complete retention in the hydrophilic group (P = 0.03). On the other hand, Schlueter et al., 2013[21] showed a statistically significant difference with more retention in the hydrophobic group (P ≤ 0.001).

Non-RCTs with 12 months follow-up

Four non-RCTs[19],[20],[25],[26] investigated the retention of hydrophilic and hydrophobic RBSs without bonding after 12 months follow-up period. Due to their inconsistency and plausible confounder, the quality of evidence was “extremely low” [Appendix 2 Table S6]. The findings from studies showed inconsistent results when pooled together, all studies favored the hydrophilic group except Topal and Kirzioğlu, 2019[26] who favored the hydrophobic group. Furthermore, in the study design, Mohanraj et al., 2019[25] and Topal & Kirziolu, 2019[26] did not address elements that may affect sealant retention and may act as confounding factors, such as nutrition, dental hygiene practice, and masticatory forces which downgraded the plausible confounder.

Retention of hydrophilic and hydrophobic RBSs with a bonding agent

RCTs with 6 months follow-up

Two RCTs[20],[27] investigated the retention of hydrophilic and hydrophobic RBSs utilizing bonding agents in permanent posterior teeth of children after 6 months follow-up period. The quality of evidence was “very low” due to their indirectness and plausible confounder [Appendix 2 Table S7]. Both studies were conducted in a single country (India) which downgraded their indirectness. In addition, the plausible confounding level was downgraded due to Baheti et al., 2020[27] who did not consider conditions that may affect the retention of sealants in their study plan which may act as confounding elements such as food, masticatory forces, and oral hygienic practices.

Non-RCTs with 12 months follow-up

Two non-RCTs[20],[27] investigated the retention of hydrophilic and hydrophobic RBSs with a layer of bonding after a 1 year follow-up period. The quality of evidence was “extremely low” due to their inconsistency, indirectness, and plausible confounder [Appendix 2 Table S8]. The inconsistency was downgraded due to the discrepancy between Bhat et al., 2013[20] who favored complete retention with the hydrophobic group while Baheti et al., 2020[27] favored the hydrophilic group.

Cariostatic effect of hydrophilic and hydrophobic RBSs

RCTs with 6 months follow-up

Two RCTs[22],[29] investigated the cariostatic effect of hydrophilic and hydrophobic RBSs in permanent posterior teeth of children after 6 months follow-up period. The quality of evidence was “low” [see Appendix 2 Table S9]. The reason for the quality downgrading was related to the inconsistency of results and indirectness that would reduce their effectiveness as both trials were conducted in a single country, which is India.

RCTs with 12 months follow-up

Two RCTs[21],[22] investigated the cariostatic effect of hydrophilic and hydrophobic RBSs in permanent posterior teeth of children after 12 months follow-up period. The evidence's quality was “poor” because of its inconsistency and inaccuracy which would reduce its effect [see Appendix 2 Table S10]. The inconsistency was downgraded due to the difference between Khatri et al., 2015[22] who reported more caries within the hydrophobic group, and Schlueter et al., 2013[21] who found more caries within the hydrophilic group. The confidence interval (CI) was wide between the two trials, which downgraded the inaccuracy.

Non-RCTs with 12 months follow-up

Two non-RCTs[20],[25],[27] investigated the cariostatic effect of hydrophilic and hydrophobic RBSs after 12 months follow-up period. The evidence's quality was “extremely low” because of the inconsistency, indirectness, and plausible confounder [see Appendix 2 Table S11]. All studies were conducted in a single country (India) which downgraded their indirectness. The plausible confounding level was downgraded due to Mohanraj et al., 2019[25] who did not consider conditions such as diet and oral hygiene maintenance level that could affect caries incidence in the study design. The findings from studies showed inconsistent results when pooled together, Bhat et al., 2013[20] showed similar caries incidence in both groups but Mohanraj et al., 2019[25] showed more caries in the hydrophilic group.

Meta-analysis

Retention of both sealants without bonding after 3- and 6-month follow-up period from pooled RCTs and non-RCTs showed no statistically significant difference in retention favoring hydrophilic RBSs with moderate heterogeneity, Z = 1.43, P < 0.15, I2 = 61%. The meta-analysis results are presented in [Figure 4]a. Retention from two RCTs without bonding for 1-year follow-up were not pooled due to high heterogeneity, I2 = 97% [Appendix 3]. However, retention of both sealants without bonding from pooled non-RCTs with 12 months follow-up showed that all studies favored the hydrophilic group except Topal and Kirzioğlu, 2019 who favored the hydrophobic group.[26] However, there was not any statistical significance between the two groups with no heterogeneity, Z = 1.57, P = 0.12, I2 = 0%. The meta-analysis results are presented in [Figure 4]b.
Figure 4: (a) Forest plot showing meta- analysis of hydrophilic and hydrophobic resin-based sealants groups without bonding reporting retention from randomized clinical trials and non-randomized clinical trials after a 3- and 6-month follow-up period. (b) Forest plot showing meta-analysis of hydrophilic and hydrophobic resin-based sealants groups without bonding reporting retention from non-randomized clinical trials after a 1-year follow-up period

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About retention of both sealants with bonding, this question was answered by only non-RCTs. Meta-analysis revealed no statistically significant difference in retention preferring hydrophilic RBSs with minor heterogeneity at 6 and 12 months, Z = 0.87, P=0.39, I2 = 36% [Figure 5]. Additionally, one RCT[28] compared with hydrophilic and hydrophobic with bonding for 6 months follow-up was not pooled because there was no other RCT with bonding. Sensitivity analysis was used after adding all studies that investigated the retention of both sealants with and without bonding at 3, 6, and 12 months. The results were consistent with our results [Appendix 4].
Figure 5: Forest plot showing meta-analysis of hydrophilic and hydrophobic resin-based sealants groups with bonding reporting retention from non-randomized clinical trials after a 6- and 12-month follow-up period

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Questioning the cariostatic effect of both sealants, this was answered by pooling both RCTs and non-RCTs. With moderate heterogeneity, the meta-analysis revealed no significant difference in caries between the two groups after 6 and 12 months, Z = 0.56, P=0.58, I2 = 59%. However, hydrophilic RBSs were associated with more caries incidence than hydrophobic RBSs [Figure 6].
Figure 6: Forest plot showing meta-analysis of hydrophilic and hydrophobic resin-based sealants groups reporting cariostatic effect from RCTs and non-RCTs after a 6- and 12-month follow-up period

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   Discussion Top


The goal of this systematic review was to evaluate and compare the retention and cariostatic effect of both hydrophilic and hydrophobic RBSs with and without bonding agents in primary and/or permanent teeth. Twelve articles were found to be suitable for inclusion in the qualitative synthesis. The data of only 10 articles were able to be combined in the meta-analysis after quality assessment. The main findings of this study showed no significance statistically in the retention and cariostatic effect between both types of sealants. Furthermore, in studies using bonding agents with hydrophobic sealants, both forms of sealants showed comparable results. Taking this into account, we can suggest that hydrophilic RBSs can be an ideal alternative to conventional RBSs, especially in cases where complete isolation cannot be achieved.

We considered studies in our systematic review that compared the retention and cariostatic effect of both types of sealants with or without the addition of an adhesive layer immediately before sealant application. The meta-analysis identified and included RCTs and non-RCTs. Because the number of randomized studies is low, non-randomized trials were included. There were 12 articles found that met the inclusion criteria. Only seven were RCTs, with the remaining being non-RCTs, indicating that there is a danger of selection bias in these studies; therefore, the findings should be interpreted with caution.

The minimum follow-up periods were determined to be at least 3 months to detect the effectiveness of both sealants as shorter follow-up periods would probably be enough to evaluate the differences between these types of sealants. The analysis pooled the results of both similar and different follow-up periods (3, 6, 12 months) but analysis of RCTs and non-RCTs were done separately to avoid bias in the study results. The most frequent follow-up period in the selected studies was 12 months[17],[19],[20],[21],[22],[24],[25],[26],[27] which was considered a suitable duration for proper evaluation of the clinical performance of sealants.

The effectiveness of both sealants was determined in the inclusion criteria to be assessed by retention and cariostatic effect because complete sealant retention over a longer period would result in a longer period of caries prevention.[10] Data from primary and permanent teeth were also determined to be considered in our meta-analysis since the enamel bond strength of both dentitions have been proven to be identical,[39] however no studies have been conducted on primary teeth comparing both sealants. As a result, we limited the meta-analysis to data from permanent molars. Thus, we encourage conducting future RCTs, investigating the clinical efficacy, retention, and cariostatic effect of both hydrophobic and hydrophilic RBSs with and without bonding agents among the primary teeth.

The GRADE criteria for assessing evidence strength recognize the significance of assessing evidence from trials with different designs. RCTs offer moderate-quality evidence which is classified at first as “high” while non-RCTs offer a very low-quality evidence which is classified at first as “low.”[40] However, caution should be applied when relying on any non-RCT as there is no established control for the known and the unknown confounding factors.

In this systematic review, retention of both sealants with and without bonding agent from the pooled non-RCTs after 12 months indicated no significant difference between both groups. However, the results of the meta-analysis of the sealants without bonding favored hydrophilic RBSs which can be explained by the sealant's ability to penetrate deeper into pits and fissures even in presence of moisture.[14] Moreover, a meta-analysis of the sealants with bonding after 12 months favored hydrophilic RBSs. However, hydrophobic sealants with bonding showed more retention success rate than hydrophobic without bonding. This may be attributed to the application of a low-viscosity hydrophilic adhesive system under the hydrophobic RBSs. These findings were in agreement with Feigal et al., 2000[41] who revealed that the application of a bonding agent improves the retention of hydrophobic RBSs. Additionally, our results were found to be consistent with the American Academy of Pediatric Dentistry guidelines which recommend the use of adhesive systems before the application of hydrophobic sealants to increase their retention.[3]

Furthermore, the current meta-analysis found no difference statistically between the two groups after 12 months regarding caries incidence under both sealants after pooling the results of both RCTs and non-RCTs. This disagrees with Mohnraj et al., 2019[25] who reported that after a 1-year follow-up, hydrophilic RBSs were associated with more caries incidence than hydrophobic RBSs. This could be due to changes in study design compared to the other included non-RCTs as they did not consider many confounders such as diet, masticatory forces, and oral hygiene maintenance level.

Nonetheless, the results of the included studies on sealant retention exhibited some inconsistencies in our meta-analysis. The usage of different types of hydrophobic sealants could be one of the explanations for this variance. While Helioseal® (Ivoclar Vivadent AG, Schaan, Liechtenstein) showed higher retention rates, other materials, such as Clinpro (3M ESPE, St. Paul, MN, USA) and Delton FS (Dentsply International, York, PA) showed lower retention rates.

The differences between these sealants could be explained by the change in the composition of different sealants and the grouping design of included non-RCTs.

After 12 months follow-up period, two RCTs were not pooled due to high statistical heterogeneity. Statistical heterogeneity is usually caused by clinical or methodological heterogeneity, which makes it difficult to determine the accuracy of meta-analyses with any certainty.[42] However, in this meta-analysis, the presence of a wide CI may be explained by the use of a random-effects model and the increased heterogeneity between the included trials.[43],[44]

It is important to acknowledge the strengths and limitations of this systematic review. Starting with the strengths, it is the first one addressing such research questions using qualitative analysis and meta-analysis approaches.[30],[31],[32],[38] As there was no specific patient or a specific type of sealant eligibility criteria adopted in this review in addition to the wide array of clinical settings in the included studies, the conclusions could be generalized for all patients. The GRADE framework for assessing the body of evidence is another of the study's strengths. Heterogeneity was also mild to moderate among the studies included [Figure 4]a, [Figure 5], [Figure 6]. It is possible that this is due to the fact that most clinical trials were performed on a single population, India.

On the other hand, one of the study limitations is the limited number of included trials where the meta-analyses of some findings might lack adequate power and for most outcomes did not allow accurate evaluations of heterogeneity, small-study effects, and reporting biases. Furthermore, we only considered studies written in English in this systematic review. Although this may appear to limit the number of studies accessible, previous studies have found no evidence of bias in meta-analyses created by language restrictions.[45],[46] In addition, combining the evidence is more challenging in the presence of different confounding variables such as the use of bonding agents and caries. Also, a substantial decline in available longevity data has to be considered and can be seen between the 3 months and 1 year follow-up periods. This limitation highlights the necessity of well-conducted RCTs with follow-up time longer than 2 years.

Few RCTs and non-RCTs exploring whether hydrophilic RBSs were equivalent to hydrophobic RBSs in sealing molars of children aged 5 to 15 years were found in this systematic review. The lack of high-quality RCTs examining the retention and cariostatic effect of hydrophilic RBSs versus hydrophobic RBSs underscores the necessity for high-quality, well-designed RCTs.

To reduce the effect of confounding factors, future research should consider using a typical protocol and design, such as random sequence generation and split-mouth design. To reduce any reporting bias, coming scientific trials should consider documenting other procedural data that may affect the outcomes, such as operator training, evaluation criteria, and clinical process specifics.


   Conclusion Top


The following are the results of this systematic review, which give consistent moderate to extremely low-quality evidence:

  1. After 3, 6, and 12 months of follow-up, there was no statistical significance in the retention of hydrophilic and hydrophobic RBSs without a bonding agent.
  2. After a 6- and 12-month follow-up, there was no significant statistical difference in the retention of both sealants with a bonding agent.
  3. Comparable cariostatic effects of both types of sealants were found after 6- and 12-month follow-ups.


Author contributions

H. Alharthy, contributed to conception, design, data acquisition, analysis, and interpretation, drafted and critically revised the manuscript; H. Elkhodary, A. Nadhreen, contributed to conception, data analysis, and interpretation, drafted and critically revised the manuscript; A. Altuwirqi, contributed to data acquisition, critically revised the manuscript; K. Baghlaf, contributed to conception, design, data analysis, and critically revised the manuscript. All authors gave final approval and agreed to be accountable for all aspects of the work.

Acknowledgements

This project was funded by the Deanship of Scientific Research (DSR) at King Abdulaziz University, Jeddah, under grant no. G: 136-165-1443. The authors, therefore, acknowledge with thanks to DSR for technical and financial support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


   Appendix 1. Databases of published studies, keywords, total numbers of articles (1873) Top


PubMed Searched

(06/09/2021)

(“pit and fissure sealants”[MeSH Terms] OR (“pit”[All Fields] AND “fissure”[All Fields] AND “sealants”[All Fields]) OR “pit and fissure sealants”[All Fields] OR (“fissure”[All Fields] AND “sealant”[All Fields]) OR “fissure sealant”[All Fields] OR (“sealant”[All Fields] OR “sealants”[All Fields]) OR (“resin s”[All Fields] OR “resinous”[All Fields] OR “resins, plant”[MeSH Terms] OR (“resins”[All Fields] AND “plant”[All Fields]) OR “plant resins”[All Fields] OR “resin”[All Fields] OR “resins”[All Fields])) AND (“hydrophile”[All Fields] OR “hydrophiles”[All Fields] OR “hydrophilically”[All Fields] OR “hydrophilics”[All Fields] OR “hydrophility”[All Fields] OR “hydrophilization”[All Fields] OR “hydrophilize”[All Fields] OR “hydrophilized”[All Fields] OR “hydrophilizing”[All Fields] OR “hydrophobic and hydrophilic interactions”[MeSH Terms] OR (“hydrophobic”[All Fields] AND “hydrophilic”[All Fields] AND “interactions”[All Fields]) OR “hydrophobic and hydrophilic interactions”[All Fields] OR “hydrophilic”[All Fields] OR “hydrophilicities”[All Fields] OR “hydrophilicity”[All Fields] OR “hydrophillic”[All Fields] OR ((“moisture”[All Fields] OR “moistures”[All Fields] OR “moisturisation”[All Fields] OR “moisturiser”[All Fields] OR “moisturisers”[All Fields] OR “moisturising”[All Fields] OR “moisturization”[All Fields] OR “moisturize”[All Fields] OR “moisturized”[All Fields] OR “moisturizer”[All Fields] OR “moisturizers”[All Fields] OR “moisturizes”[All Fields] OR “moisturizing”[All Fields]) AND (“immune tolerance”[MeSH Terms] OR (“immune”[All Fields] AND “tolerance”[All Fields]) OR “immune tolerance”[All Fields] OR “tolerance”[All Fields] OR “drug tolerance”[MeSH Terms] OR (“drug”[All Fields] AND “tolerance”[All Fields]) OR “drug tolerance”[All Fields] OR “tolerabilities”[All Fields] OR “tolerability”[All Fields] OR “tolerable”[All Fields] OR “tolerableness”[All Fields] OR “tolerably”[All Fields] OR “tolerances”[All Fields] OR “tolerant”[All Fields] OR “tolerants”[All Fields] OR “tolerate”[All Fields] OR “tolerated”[All Fields] OR “tolerates”[All Fields] OR “tolerating”[All Fields] OR “toleration”[All Fields] OR “tolerator”[All Fields] OR “tolerators”[All Fields] OR “tolerence”[All Fields]))) AND (“hydrophobe”[All Fields] OR “hydrophobes”[All Fields] OR “hydrophobic and hydrophilic interactions”[MeSH Terms] OR (“hydrophobic”[All Fields] AND “hydrophilic”[All Fields] AND “interactions”[All Fields]) OR “hydrophobic and hydrophilic interactions”[All Fields] OR “hydrophobic”[All Fields] OR “hydrophobicities”[All Fields] OR “hydrophobicity”[All Fields] OR “hydrophobically”[All Fields] OR “hydrophobics”[All Fields] OR “hydrophobization”[All Fields] OR “hydrophobize”[All Fields] OR “hydrophobized”[All Fields] OR “hydrophobizing”[All Fields] OR (“conventional”[All Fields] OR “conventionals”[All Fields])) AND (“retention, psychology”[MeSH Terms] OR (“retention”[All Fields] AND “psychology”[All Fields]) OR “psychology retention”[All Fields] OR “retention”[All Fields] OR “retentions”[All Fields] OR “retentive”[All Fields] OR “retentiveness”[All Fields] OR (“success”[All Fields] OR “successes”[All Fields] OR “successful”[All Fields]) OR (“carie”[All Fields] OR “dental caries”[MeSH Terms] OR (“dental”[All Fields] AND “caries”[All Fields]) OR “dental caries”[All Fields] OR “caries”[All Fields])) {226}

ScienceDirect Searched via King Abdulaziz University

(06/09/2021)

(Fissure sealant) OR (sealant) AND (resin) AND (hydrophilic) AND (hydrophobic) AND (retention) {588}

Scopus Wiley Searched via King Abdulaziz University

(06/09/2021)

(Fissure sealant) OR (sealant) AND (resin) AND (moisture tolerant) OR (hydrophilic) AND (hydrophobic) OR (conventional) AND (retention) OR (success) {214}

Cochrane library Searched

(06/09/2021)

(Pit and fissure sealant) OR (Fissure sealant) OR (sealant) AND (resin) AND (moisture tolerant) OR (hydrophilic) AND (hydrophobic) OR (conventional) AND (retention) OR (success) OR (Caries) {619}

ClinicalTrials.gov library Searched

(06/09/2021)

(Fissure sealant) OR (sealant) AND (resin) AND (moisture tolerant) OR (hydrophilic) AND (hydrophobic) OR (conventional) AND (retention) OR (success) OR (Caries) {33}

Other sources: Google scholar Searched

(06/09/2021)

(Fissure sealant) OR (sealant) AND (resin) AND (moisture tolerant) OR (hydrophilic) AND (hydrophobic) OR (conventional) AND (retention) OR (success) OR (Caries) {1130}.

Appendix 2. Grade Profile Tables

Table S1 QUESTION: Is the application of hydrophilic resin-based sealants (moisture-tolerant) clinically in primary and permanent posterior teeth without bonding comparable to the conventional hydrophobic resin-based sealants in terms of retention?

Settings: General child population (5–15 years)



1Two randomized clinical trials Khatri et al.,[22] 2015 and Prabakar et al., 2018)[24] investigated the retention of hydrophilic and hydrophobic resin-based sealants without bonding in permanent posterior teeth in children.

2Both studies were split-mouth designs and had a low risk of bias; therefore, there was no downgrading for the risk of bias.

3No downgrading for inconsistency because Khatri et al., 2015[22] showed complete retention in 81% in the hydrophilic group and 66% in the hydrophobic group which is consistent with Prabakar et al., 2018[24] results which showed complete retention in 78.3% of the hydrophilic group and 46.7% of hydrophobic group at the end of 3 months. However, a statistically significant difference was found (p = 0.0002) in retention; when both trials are pooled together, it favored hydrophilic resin-based sealant (OR: 3.40; C.I 95%: 1.77, 6.55).

4Data were downgraded one level for indirectness because both trials were conducted in India.

5No downgrading for imprecision, both confidence intervals (CI) were not wide and no overlap was founded between the studies. The calculated odds ratio of Khatri et al.,[22] 2015 was (OR: 2.27; C.I 95%: 0.72, 7.16) and the calculated odds ratio of Prabakar et al., 2018[24] was (OR: 4.13; C.I 95%: 1.86, 9.16).

6No downgrading due to the plausible confounding that would reduce the demonstration effect. Studies were split-mouth to eliminate the other confounding factors such as diet and oral hygiene maintenance level.

7Total number of teeth from the two randomized trials.

8Meta-analysis was pooled and showed a statistically significant difference in retention, which favored hydrophilic resin-based sealants with no heterogeneity, Z = 3.67, P < 0.001, I2 = 0%.

Table S2 QUESTION: Is the application of hydrophilic resin-based sealants (moisture-tolerant) clinically in primary and permanent posterior teeth without bonding comparable to the conventional hydrophobic resin-based sealants in terms of retention?

Settings: General child population (5–15 years)



1Two non-RCTs (Bhatia et al., 2012[19] and Mohanraj et al., 2019)[25] investigated the retention of hydrophilic and hydrophobic resin-based sealants without bonding in permanent posterior teeth in children with 3 months follow-up. All studies showed no statistically significant difference in complete retention between hydrophilic and hydrophobic resin-based sealants without bonding.

2All studies were classified as good to fair; therefore, there was no downgrade for the risk of bias.

3Data were not downgraded due to evidence of inconsistency. The findings from studies showed consistent results when pooled together, all studies favored the hydrophilic group. However, the difference between the two groups was not statistically significant (p = 0.65) and the calculated odds ratio was (OR: 1.11; C.I 95%: 0.71, 1.72).

4Data were downgraded one level for indirectness because all studies were conducted in India.

5No downgrading for imprecision, CI was not wide, and no overlap was founded between the studies. The calculated odds ratio of Bhatia et al., 2012[19] was (OR: 1.28; C.I 95%: 0.48, 3.42) and Mohanraj et al., 2019[25] was (OR: 1.07; C.I 95%: 0.65, 1.75).

6Downgrading one level due to the plausible confounding in Mohanraj et al., 2019[25] that would reduce the effect. Bhatia et al., 2012[19] was a full-factorial design study while Mohanraj et al., 2019[25] did not consider conditions that may affect retention as study design in the selection and distribution of groups and eliminated the other confounding factors such as diet, masticatory forces, and oral hygiene practice.

7Total number of teeth from the two interventional studies.

8Meta-analysis was pooled and showed no significant difference between the two groups with no heterogeneity, Z = 0.45, P < 0.65, I2 = 0%.

Table S3 QUESTION: Is the application of hydrophilic resin-based sealants (moisture-tolerant) clinically in primary and permanent posterior teeth without bonding comparable to the conventional hydrophobic resin-based sealants in terms of retention?

Settings: General child population (5–15 years)



1Two randomized clinical trials (Khatri et al., 2015[22] and Mohapatra, et al., 2020) investigated the retention of hydrophilic and hydrophobic resin-based sealants without bonding in permanent posterior teeth in children.

2Both studies were split-mouth designs and have a low risk of bias; therefore, there was no downgrading for risk of bias.

3Data were downgraded one level due to serious inconsistency. The findings from Khatri et al., 2015[22] favored the hydrophilic group while Mohapatra, et al., 2020 favored the hydrophobic group. However, the meta-analysis showed no significant difference between the two groups (p = 0.98), and the calculated odds ratio was (OR: 0.98; C.I 95%: 0.21, 4.66).

4Data were downgraded one level for indirectness because both trials were conducted in India.

5No downgrading for imprecision, CI was not wide, and no overlap was founded between the studies. The calculated odds ratio of Khatri et al., 2015[22] was (OR: 2.14; C.I 95%: 0.71, 6.45), and the calculated odds ratio of Mohapatra, et al., 2020 was (OR: 0.44; C.I 95%: 0.14, 1.40).

6No downgrading due to the plausible confounding that would reduce the demonstration effect, studies were split-mouth to eliminate the other confounding factors such as diet and oral hygiene maintenance level.

7Total number of teeth from the two randomized trials.

8Meta-analysis was pooled and showed no significant difference between the two groups with moderate heterogeneity, Z = 0.03, P < 0.98, I2 = 74%.

Table S4 QUESTION: Is the application of hydrophilic resin-based sealants (moisture-tolerant) clinically in primary and permanent posterior teeth without bonding comparable to the conventional hydrophobic resin-based sealants in terms of retention?

Settings: General child population (5–15 years)



1Three non-RCTs (Bhatia et al.,[19] 2012, Bhat et al.,[20] 2013, and Mohanraj et al., 2019)[25] investigated the retention of hydrophilic and hydrophobic resin-based sealants without bonding in permanent posterior teeth in children with 6 months follow-up. All studies showed no statistically significant difference in complete retention between hydrophilic and hydrophobic resin-based sealants without bonding.

2All studies were classified as good to fair; therefore, there was no downgrade for the risk of bias.

3Data were downgraded one level due to evidence of inconsistency. The findings from studies showed inconsistent results when pooled together, all studies favored the hydrophobic group except Bhat et al., 2013[20] on the side of hydrophilic group. However, the difference between the two groups was not statistically significant (p = 0.77), and the calculated odds ratio was (OR: 1.10; C.I 95%: 0.59, 2.05).

4Data were downgraded one level for indirectness because all studies were conducted in India.

5No downgrading for imprecision, CI was not wide, and no overlap was founded between the studies. The calculated odds ratio of Bhatia et al., 2012[19] was (OR: 0.89; C.I 95%: 0.34, 2.30), Bhat et al., 2013[20] was (OR: 2.41; C.I 95%: 0.92, 6.27), and Mohanraj et al., 2019[25] was (OR: 0.82; C.I 95%: 0.54, 1.24).

6Downgrading one level due to the plausible confounding in Mohanraj et al., 2019[25] that would reduce effect. Bhatia et al., 2012[19] and Bhat et al., 2013[20] were full-factorial design while Mohanraj et al., 2019[25] did not consider conditions that may affect retention as study design in selection and distribution of groups and to eliminate the other confounding factors such as diet, masticatory forces, and oral hygiene practice.

7Total number of teeth from the three interventional studies.

8Meta-analysis was pooled and showed no significant difference between the two groups with moderate heterogeneity, Z = 0.29, P < 0.77, I2 = 52%.

Table S5 QUESTION: Is the application of hydrophilic resin-based sealants (moisture-tolerant) clinically in primary and permanent posterior teeth without bonding comparable to the conventional hydrophobic resin-based sealants in terms of retention?

Settings: General child population (5–15 years)



1Two randomized clinical trials (Khatri et al., 2015[22] and Schlueter et al., 2013)[21] investigated the retention of hydrophilic and hydrophobic resin-based sealants without bonding in permanent posterior teeth in children.

2Both studies were split-mouth designs and have a low risk of bias; therefore, there was no downgrading for risk of bias.

3Data were downgraded one level due to serious inconsistency. The findings from Khatri et al., 2015[22] showed statistically significant more complete retention in the hydrophilic group (p = 0.03); however, Schlueter et al., 2013[21] showed statistically significant more retention in the hydrophobic group (p ≤ 0.001).

4Data were not downgraded for indirectness because both studies were conducted on children and conducted in India and Germany.

5No downgrading for imprecision, CI was not wide, and no overlap was founded between the studies. The calculated odds ratio of Khatri et al., 2015[22] was (OR: 2.56; C.I 95%: 0.91, 7.20) and the calculated odds ratio of Schlueter et al., 2013[21] was (OR: 0.03; C.I 95%: 0.01, 0.10).

6No downgrading due to the plausible confounding that would reduce demonstration effect, studies were split-mouth to eliminate the other confounding factors such as diet and oral hygiene maintenance level.

7Total number of teeth from the two randomized trials.

8Not pooled due to high heterogeneity, I2 = 97%.

Table S6 QUESTION: Is the application of hydrophilic resin-based sealants (moisture-tolerant) clinically in primary and permanent posterior teeth without bonding comparable to the conventional hydrophobic resin-based sealants in terms of retention?

Settings: General child population (5–15 years)



1Four non-RCTs (Bhatia et al.,[19] 2012, Bhat et al., 2013,[20] Mohanraj et al.,[25] 2019 and Topal & Kirzioğlu, 2019)[26] investigated the retention of hydrophilic and hydrophobic resin-based sealants without bonding in permanent posterior teeth in children with 1-year follow-up.

2All studies were classified as good to fair; therefore, there was no downgrade for the risk of bias.

3Data were downgraded one level due to serious inconsistency. The findings from studies showed inconsistent results when pooled together, all studies favored the hydrophilic group except Topal & Kirzioğlu, 2019[26] on the side of hydrophobic group. However, the difference between the two groups was not statistically significant (p = 0.12) and the calculated odds ratio was (OR: 1.34; C.I 95%: 0.93, 1.93).

4Data were not downgraded for indirectness because studies were conducted on children and conducted in India and Turkey.

5No downgrading for imprecision, CI was not wide, and no overlap was founded between the studies. The calculated odds ratio of Bhatia et al., 2012[19] was (OR: 1.44; C.I 95%: 0.44, 4.70), Bhat et al., 2013[20] was (OR: 1.55; C.I 95%: 0.73, 3.31), Mohanraj et al., 2019[25] was (OR: 1.72; C.I 95%: 0.89, 3.31), and Topal & Kirzioğlu, 2019[26] was (OR: 0.97; C.I 95%: 0.52, 1.78).

6Downgrading one level due to the plausible confounding in Mohanraj et al., 2019[25] and Topal & Kirzioğlu, 2019[26] that would reduce the effect. Bhatia et al.,[19] 2012 and Bhat et al.,[20] 2013 were full-factorial designs while Mohanraj et al.,[25] 2019 and Topal & Kirzioğlu, 2019[26] did not consider conditions that may affect retention as study design in the selection and distribution of groups in all children to eliminate the other confounding factors such as diet, masticatory forces, and oral hygiene practice.

7Total number of teeth from the four interventional studies.

8Meta-analysis was pooled and showed no significant difference between both groups with no heterogeneity, Z = 1.57, P = 0.12, I2 = 0%.

Table S7 QUESTION: Is the application of hydrophilic resin-based sealants (moisture-tolerant) clinically in primary and permanent posterior teeth with a layer of bonding agent comparable to the conventional hydrophobic resin-based sealants in terms of retention?

Settings: General child population (5–15 years)



1Two non-RCTs (Bhat et al.,[20] 2013 and Baheti et al., 2020)[27] investigated the retention of hydrophilic and hydrophobic resin-based sealants with a layer of bonding in permanent posterior teeth in children with 6 months follow-up.

2Both studies were assessed as good level; therefore, there was no downgrade for risk of bias.

3No downgrading for inconsistency because Both studies showed no statistically significant difference in retention between hydrophilic and hydrophobic resin-based sealants with bonding. Bhat et al.,[20] 2013 showed complete retention in 73 teeth in the hydrophilic group and 72 teeth in the hydrophobic group which is consistent with the results of Baheti et al., 2020[27] that showed complete retention of 30 teeth in the hydrophilic group and 27 teeth in the hydrophobic group at the end of 6 months.

4Data were downgraded one level for indirectness because both studies were conducted in India.

5Downgrading for imprecision, the CI was wide between the two studies. The calculated odds ratio of Bhat et al.,[20] 2013was (OR: 1.16; C.I 95%: 0.40, 3.36) and Baheti et al.,[27] 2020 was (OR: 7.76; C.I 95%: 0.38, 157.14).

6Downgrading one level due to the plausible confounding in Baheti et al.,[27] 2020 that would reduce demonstration effect. Bhat et al.,[20] 2013 was a full-factorial design, and Baheti et al.,[27] 2020 did not consider the condition that may affect retention as study design in the selection and distribution of groups in all children equally to eliminate the other confounding factors such as diet, masticatory forces, and oral hygiene maintenance level.

7Total number of teeth from the two interventional studies.

8Meta-analysis pooled and there was no statistically significant difference (P = 0.48) in retention between hydrophilic and hydrophobic resin-based sealant (OR: 1.77; C.I 95%: 0.37, 8.61) with moderate heterogeneity, Z = 0.71, I2 = 29.

Table S8 QUESTION: Is the application of hydrophilic resin-based sealants (moisture-tolerant) clinically in primary and permanent posterior teeth with a layer of bonding agent comparable to the conventional hydrophobic resin-based sealants in terms of retention?

Settings: General child population (5–15 years)



1Two non-RCTs (Bhat et al.,[20] 2013 and Baheti et al., 2020)[27] investigated the retention of hydrophilic and hydrophobic resin-based sealants with a layer of bonding in permanent posterior teeth in children at the end of 1-year follow-up.

2Both studies were assessed as low-level; therefore, there was no downgrade for risk of bias.

3Data were downgraded one level due to evidence of inconsistency. The findings from two studies showed inconsistent results where Bhat et al.,[20] 2013 showed complete retention more in the hydrophobic group and Baheti et al.,[27] 2020 showed more complete retention in the hydrophilic group

4Data were downgraded one level for indirectness because both studies were conducted in India.

5Downgrading one level for imprecision, CI was wide between the two studies. The calculated odds ratio of Bhat et al.,[20] 2013 was (OR: 0.91; C.I 95%: 0.41, 2.06) and Baheti et al.,[27] 2020 was (OR: 13.24; C.I 95%: 0.70, 251.60).

6Downgrading one level due to the plausible confounding in Baheti et al.,[27] 2020 that would reduce demonstration effect. Bhat et al.,[20] 2013 was a full-factorial design and Baheti et al., 2020[27] did not consider condition that may affect retention as study design in selection and distribution of groups in all children equally to eliminate the other confounding factors such as diet, masticatory forces and oral hygiene maintenance level.

7Total number of teeth from the two interventional studies.

8Meta-analysis pooled and the difference between the two groups was not statistically significant (p = 0.46) and the calculated odds ratio was (OR: 1.32; CI 95%: 0.63, 2.73) with moderate heterogeneity, Z = 0.67, I2 = 68%.

Table S9 QUESTION: Is the application of hydrophilic resin-based sealants (moisture-tolerant) in primary and permanent posterior teeth comparable to the conventional hydrophobic resin-based sealants in terms of the cariostatic effect?

Settings: General child population (5-15 years) population



1Two randomized clinical trials (Khatri et al.,[22] 2015 and Mohapatra, et al., 2020) investigated the cariostatic effect of hydrophilic and hydrophobic resin-based sealants in permanent posterior teeth in children.

2Both studies were split-mouth designs and have a low risk of bias; therefore, there was no downgrading for risk of bias.

3Data were downgraded one level due to serious inconsistency. The findings from Khatri et al.,[22] 2015 showed more caries incidence in the hydrophobic group while Mohapatra, et al., 2020 showed more caries incidence in the hydrophilic group. However, the meta-analysis showed no significant difference between the two groups (p = 0.81), and the calculated odds ratio was (OR: 0.87; C.I 95%: 0.29, 2.61).

4Data were downgraded one level for indirectness because both trials were conducted in India.

5No downgrading for imprecision, CI was not wide and no overlap was founded between the studies. The calculated odds ratio of Khatri et al.,[22] 2015 was (OR: 0.47; C.I 95%: 0.08, 2.75) and the calculated odds ratio of Mohapatra, et al., 2020 was (OR: 1.28; C.I 95%: 0.32, 5.13).

6No Downgrading due to the plausible confounding that would reduce demonstration effect, studies were split-mouth to eliminate the other confounding factors such as diet and oral hygiene maintenance level.

7Total number of teeth from the two randomized trials.

8Meta-analysis was pooled and showed no significant difference between the two groups with no heterogeneity, Z = 0.24, P < 0.81, I2 = 0%.

Table S10 QUESTION: Is the application of hydrophilic resin-based sealants (moisture-tolerant) in primary and permanent posterior teeth comparable to the conventional hydrophobic resin-based sealants in terms of the cariostatic effect?

Settings: General child population (5-15 years) population



1Two randomized clinical trials (Khatri et al.,[22] 2015 and Schlueter et al.,[21] 2013) investigated the cariostatic effect of hydrophilic and hydrophobic resin-based sealants in permanent posterior teeth in children.

2Both studies were split-mouth designs and have a low risk of bias; therefore, there was no downgrade for risk of bias.

3Data were downgraded one level due to evidence of inconsistency. The findings from Khatri et al.,[22] 2015 showed more caries incidence in the hydrophobic group and Schlueter et al.,[21] 2013 showed more caries incidence in the hydrophilic group. However, the difference between the two groups was not statistically significant (p = 1.00) and the calculated odds ratio was (OR: 1.01; C.I 95%: 0.08, 13.17).

4Data were not downgraded for indirectness because studies were conducted on children and conducted in India and Germany.

5Downgrading for imprecision, CI was wide between the two trials. The calculated odds ratio of Khatri et al.,[22] 2015 was (OR: 0.36; C.I 95%: 0.06, 2.01) and Schlueter et al.,[21] 2013 was (OR: 5.19; C.I 95%: 0.24, 110.57).

6No downgrading due to the plausible confounding that would reduce demonstration effect, studies were split-mouth to eliminate the other confounding factors such as diet and oral hygiene maintenance level.

7Total number of teeth from the two randomized trials.

8Meta-analysis was pooled and no significant difference between both groups in cariostatic effect and the analysis was with moderate heterogeneity, Z = 0, P = 1, I2 = 56%.

Table S11 QUESTION: Is the application of hydrophilic resin-based sealants (moisture-tolerant) in primary and permanent posterior teeth comparable to the conventional hydrophobic resin-based sealants in terms of the cariostatic effect?

Settings: General child population (5-15 years) population



1Two non-RCTs (Bhat et al.,[20] 2013 and Mohanraj et al., 2019)[25] investigated the cariostatic effect of hydrophilic and hydrophobic resin-based sealants in permanent posterior teeth in children.

2Both studies were classified as good to fair risk of bias; therefore, there was no downgrade for risk of bias.

3Data were downgraded one level due to evidence of inconsistency. Bhat et al.,[20] 2013 showed no statistically significant difference in presence of caries between hydrophilic and hydrophobic resin-based sealants. However, Mohanraj et al.,[25] 2019 showed a significant difference in caries incidence in the hydrophilic group more than in the hydrophobic group (P = 0.001). The findings from studies showed inconsistent results when pooled together, Bhat et al.,[20] 2013 showed similar caries incidence in both groups but Mohanraj et al.,[25] 2019 showed more caries in the hydrophilic group. However, the difference between the two groups was not statistically significant (p = 0.07) and the calculated odds ratio was (OR: 2.78; C.I 95%: 0.90, 8.56).

4Data were downgraded one level for indirectness because both studies were conducted in India.

5No downgrading for imprecision, CI was not wide and no overlap was founded between the studies. The calculated odds ratio of Bhat et al.,[20] 2013 was (OR: 1.00; C.I 95%: 0.14, 7.29) and Mohanraj et al.,[25] 2019 was (OR: 3.84; C.I 95%: 2.16, 6.82).

6Downgrading one level due to the plausible confounding in Mohanraj et al.,[25] 2019 that would reduce demonstration effect. Bhat et al.,[20] 2013 was a full-factorial design. Mohanraj et al.,[25] 2019 did not consider conditions that may affect caries as study design in selection and distribution of groups equally in all children to eliminate the other confounding factors such as diet and oral hygiene maintenance level.

7Total number of teeth from the two interventional studies.

8Meta-analysis was pooled and no significant differences was found between the two groups, analysis with moderate heterogeneity, Z = 1.78, P = 0.07, I2 = 38%.







 
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