d e n t a l m a t e r i a l s 3 2 ( 2 0 1 6 ) 323333

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.intl.elsevierhealth.com/journals/dema

Are uoride releasing dental materials clinically

effective on caries control?

Jaime Aparecido Cury a, , Branca Heloisa de Oliveira b ,

Ana Paula Pires dos Santos b , Livia Maria Andal Tenuta a
a Piracicaba Dental School, UNICAMP, Piracicaba, SP, Brazil
b Dental School, UERJ, Rio de Janeiro, RJ, Brazil

a r t i c l e i n f o a b s t r a c t

Keywords: Objectives. (1) To describe caries lesions development and the role of uoride in controlling
Dental caries disease progression; (2) to evaluate whether the use of uoride-releasing pit and ssure
Fluorides sealants, bonding orthodontic agents and restorative materials, in comparison to a non-
Dental materials uoride releasing material, reduces caries incidence in children or adults, and (3) to discuss
how the anti-caries properties of these materials have been evaluated in vitro and in situ.
Methods. The search was performed on the Cochrane Database of Systematic Reviews and
on Medline via Pubmed.
Results. Caries is a biolm-sugar dependent disease and as such it provokes progressive
destruction of mineral structure of any dental surface intact, sealed or restored where
biolm remains accumulated and is regularly exposed to sugar. The mechanism of action
of uoride released from dental materials on caries is similar to that of uoride found in
dentifrices or other vehicles of uoride delivery. Fluoride-releasing materials are unable to
interfere with the formation of biolm on dental surfaces adjacent to them or to inhibit acid
production by dental biolms. However, the uoride released slows down the progression
of caries lesions in tooth surfaces adjacent to dental materials. This effect has been clearly
shown by in vitro and in situ studies but not in randomized clinical trials.
Signicance. The anti-caries effect of uoride releasing materials is still not based on clinical
evidence, and, in addition, it can be overwhelmed by uoride delivered from dentifrices.
2015 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.

functional again and esthetically appealing to the patient.

1. Introduction However, when dental materials have the ability to release
Dental materials are used in Dentistry for many clinical pur- uoride, it is expected that, besides restoring function and
poses. If the material is used to rebuild the tooth and does esthetics, they may control the recurrence of caries on den-
not have properties that may help to control caries adjacent tal structure adjacent to the lling and/or even contribute to
to the lling, the role of this material is only to make the tooth reduce caries incidence in the entire dentition.

This paper was originally intended for publication with the set of papers from the Academy of Dental Materials Annual Meeting,
710 October 2015, Hawaii, USA; published in DENTAL 32/1 (2016).

Corresponding author. Tel.: +55 19 21065303.
E-mail addresses: [email protected] (J.A. Cury), [email protected] (B.H. de Oliveira), [email protected]
(A.P.P. dos Santos), [email protected] (L.M.A. Tenuta).
http://dx.doi.org/10.1016/j.dental.2015.12.002
0109-5641/ 2015 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.
324 d e n t a l m a t e r i a l s 3 2 ( 2 0 1 6 ) 323333

In addition, uoride-releasing materials are also used as

Table 1 Approaches for uoride use and vehicles for its
sealants to prevent caries in pits and ssures and as mate- delivery in the oral environment.
rials for bonding and/or cementing orthodontic brackets and
Approaches for uoride use Vehicles (examples)
bands. In this case, it is also expected that the uoride released
by these materials will work reducing the progression of Community level Water uoridation
Individual level Fluoride dentifrice,
enamel caries around them.
mouthrinse
The development of caries on dental surfaces adjacent to
Professionally applied Fluoride-releasing dental
dental materials should not be considered different from that materials, topical uoride
occurring on intact (natural) dental surfaces. Also, the mech- application (gel, varnish)
anism of action of uoride on caries control adjacent to these Combinations Fluoride
materials may be considered the same as that reported for dentifrice + uoride-
other ways or vehicles of uoride delivery, such as uoride releasing dental
materials
dentifrices (toothpastes). These concepts are discussed in Sec-
tions 2 and 3 of this paper.
Therefore, dental caries as a disease is, by nature, primary,
and its control, either in intact dental surfaces or adjacent to
dental materials (secondary caries), is achieved by biolm
2. Dental caries mechanical disruption and sugar restriction.
Also, caries is not the result of uoride deciency [7] but
Caries lesions develop on dental surfaces in which biolms are this ion is the only therapeutic agent known to effectively con-
formed, allowed to accumulate and retained for long periods of trol caries progression, and uoride-releasing materials may
time (e.g., occlusal surfaces, interproximal areas, along gingi- be considered a way or vehicle of uoride delivery (Table 1).
val margins and on enamel-cementum junction) [1]. Although
necessary for caries lesion progression, biolm accumulation
alone is not enough. Sugars are the pivotal, negative fac- 3. Fluoride effect
tor, responsible for caries lesion progression [2]. The acid pH
produced from the fermentation of dietary sugars not only The old concept that uoride strengthens the teeth, making
provokes dissolution of the underlying dental minerals, but them more resistant to caries, is still prevalent. However, u-
also selects in the biolm formed the most cariogenic bacteria oride is not able to prevent caries lesion development because
[3]. it does not avoid the formation of biolm in any dental sur-
Therefore, caries is a biolm-sugar dependent disease [1] face, either intact or adjacent to uoride-releasing materials.
and, among the dietary sugars, sucrose is the most cariogenic Furthermore, the in vivo effect of uoride inhibiting acid pro-
because besides being easily fermented into acids, it is the only duction from sugars in the biom is negligible [7].
carbohydrate that change the matrix of the biolm formed, In fact, uoride interferes with the caries process, reducing
making the biolm more cariogenic [4]. demineralization and enhancing remineralization of enamel
Thus, biolm accumulation is the necessary factor and and dentin [8]. This physico-chemical mechanism occurs
sugar exposure the negative determinant factor for caries every time sugar is ingested and the pH falls in biolm uid; if
progression in any dental surface, intact or restored (Fig. 1). uoride is present, the amount of mineral dissolved is reduced
The only difference between caries progression on enamel or because part of Ca and Pi lost as hydroxyapatite returns to the
dentin adjacent to a lling, in comparison with a natural intact tooth as uorapatite (reduction of demineralization) (Fig. 2a).
surface, is the possibility of biolm accumulation in the gap When the ingestion of sugar ceases and the pH rises again,
between the wall of the cavity and the lling material [5,6]. uoride present in the oral uids enhances the natural phe-
Every time sugar is ingested, biolm bacteria produce acids nomenon of remineralization (Fig. 2b). As a consequence, the
and, consequently, the pH drops in the biolm uid. Thus, progression of caries lesions is slowed down [7]. Also, follow-
pH is the driving force governing the loss or gain of Ca and ing the exchange of minerals between the biolm uid and
Pi from the mineral structure of the teeth. While pH remains enamel or dentin in the presence of uoride, an enrichment
below around 6.5 for dentin and 5.5 for enamel, the miner- of uoride concentration in enamel or dentin surfaces occurs
als of these tissues are dissolved (demineralization) (Fig. 1a). a consequence of the effect of uoride on the caries process,
After around 2030 min, the pH rises again and, above 5.5 for and not the cause of caries lesions reduction [9].
enamel and 6.5 for dentin, saliva tries to repair Ca and Pi loss The anti-caries effect of uoride can be obtained by the
(remineralization) (Fig. 1b). However, saliva alone is not 100% same mode of action irrespective of the ways or vehicles of
effective to repair all Ca and Pi minerals lost during the dem- uoride use. Among them, toothbrushing with uoride den-
ineralizing process. The balance toward demineralization or tifrices is the only one whose results on caries reduction
remineralization will be dependent on the daily frequency of are strongly based on scientic evidence [10]. Besides their
dietary sugars ingestion. effectiveness to control the incidence of caries in originally
Thus, caries lesions progression on dental surfaces, intact dental surfaces, uoride dentifrices can also interfere
restored or not, is provoked by the same factors, biolm accu- with caries lesion progression adjacent to dental materials
mulation and sugar exposure. Also, the process (chemical because during toothbrushing uoride is spread throughout
events) of caries lesions development is the same in any dental the mouth, and enriches remainings of biolm not perfectly
surface (Fig. 1a and b). removed [11].
 d e n t a l m a t e r i a l s 3 2 ( 2 0 1 6 ) 323333 325

Fig. 1 Enamel demineralization as a function of sugar metabolism by dental biolm. Every time sugar is ingested, a low
pH, below the critical level for the dissolution of tooth mineral (hydroxyapatite), is achieved. Tooth mineral from an intact
surface, or adjacent to a restoration, will dissolve (a). Enamel remineralization following a demineralization event. As saliva
clears out sugar and acid from the biolm, its pH increases above the critical for dissolution of tooth mineral
(hydroxyapatite). Remineralization will occur in the surfaces previously demineralized (b).

Fluoride-releasing materials should also be considered a era but most evaluations are based on in vitro and in situ
way to maintain uoride constantly in the mouth (Table 1). studies [14]. Therefore, there is a bulk of data recommending
For instance, glass ionomer cements, in addition to releasing these materials to improve oral health in terms of lower-
uoride for a long time, can also be recharged with the ion ing caries levels. However, these data accrue from studies
from other sources, such as uoride dentifrice [12]. with a low level of evidence to inform clinical practice. Cur-
Furthermore, uoride-releasing materials should be con- rently, it is acknowledged that health interventions should
sidered a unique way of uoride use because the ion is be based on the best available evidence, and the only way
maintained constant in the right place (the biolm), is avail- to know if they work in real life is by conducting random-
able at the right time (whenever sugar is ingested), and in ized clinical trials. The current available evidence from clinical
enough concentration (low levels) to reduce de- and enhance studies on uoride-releasing pit and ssure sealants, bonding
remineralization (Fig. 2a and b). orthodontic agents and restorative materials for caries control
Another advantage of uoride-releasing dental materials is presented below.
in comparison with dentifrice is that the effect of uoride
does not depend on patient compliance. Fluoride from dental
materials works passively. 4. Clinical effects of uoride-releasing
However, considering that they all work by the same mode dental materials on the development of caries
of action, a synergistic effect of the combination of ways lesions
of uoride use would not be expected. In fact, there is no
evidence of a synergistic or additive effect when uoride den- The question we sought to answer in this section of the arti-
tifrices, rinses and gels or varnishes are used in combination cle was whether the use of uoride-releasing pit and ssure
[10,13]. Thus, no signicant additive effect would be expected sealants, bonding orthodontic agents or restorative materials,
if uoride-releasing dental materials are used in a patient who in comparison to a non-uoride releasing material, reduces
brushes his/her teeth at least twice/day with dentifrice con- caries incidence in children or adults.
taining at least 1000 ppm F [5]. In order to gather the best, currently available evidence on
In fact, the anti-caries potential of uoride-releasing mate- the clinical effects of uoride-releasing materials on caries
rials has been extensively studied since the silicate cement control, we searched for published systematic reviews of
326 d e n t a l m a t e r i a l s 3 2 ( 2 0 1 6 ) 323333

Fig. 2 The mode of action of uoride on the inhibition of demineralization. The same event described in Fig. 1a is
counteracted by a simultaneous precipitation of uoride containing minerals (uorapatite) in tooth enamel if uoride is
delivered to the biolm from any source. Here, uoride from dentifrice (on the left) or from restorative materials (on the
right) are described as uoride sources for the biolm (a). The effect of uoride on the enhancement of enamel
remineralization (b). Remineralization from saliva described in Fig. 1b is boosted by uoride made available to the biolm by
uoride dentifrice or uoride-releasing materials (b).

randomized controlled trials (RCTs). The search was per- prevention of dental caries [15]. Thus, higher priority was
formed on the Cochrane Database of Systematic Reviews and given to the results of Cochrane reviews whenever they
on Medline via Pubmed, using the tool Clinical Queries and could provide information on topics that were relevant to our
the option Systematic Reviews. Searches for published RCTs research question.
were also performed in order to seek more recent studies
published after the date of the end of the search performed 4.1. Pit and ssure sealants
in the systematic reviews that we had identied and read.
The search for RCTs was performed on Medline via Pubmed Sealing pit and ssures of occlusal surfaces with a thin layer
using the tool Clinical Queries and the clinical study cate- of resin was introduced as a caries preventive method in
gory Therapy within the narrowed scope. We used different the late 1960s. Resin dental materials used for this purpose
combinations of Mesh terms and free vocabulary: dental evolved from ultraviolet to visible-light cured sealants, with
caries [mh], tooth demineralization [mh], orthodontics [mh], the newest materials having uoride incorporated into the
dental atraumatic restorative material [mh], uorides [mh], resin [16]. There is evidence to suggest that resin-based ssure
dental materials [mh], pit and ssure sealants [mh], compos- sealants are effective in preventing occlusal caries in perma-
ite resins [mh], dental cements [mh], glass-ionomer cements nent molars of children and adolescents when compared to no
[mh], compomers [mh], resin-modied glass-ionomer, giomer, sealants, but it is still not known whether uoride-releasing
nano-ionomer, and dental sealants. Commentaries on sys- resin-based sealants provide any additional benet [17].
tematic reviews and RCTs were also searched for in the The potential of glass-ionomer cements (GIC) to form a
Database of Abstracts of Reviews of Effects (DARE) and in the chemical bond to enamel thus reducing the importance of
secondary publications Evidence-based Dentistry and Journal maintaining a dry operating eld during application, and their
of Evidence-based Dental Practice. All searches were per- ability to release uoride to provide a possible cariostatic
formed in May 2015. effect, were strong motivations for their use as pit and s-
Cochrane systematic reviews are considered the high- sure sealing materials, especially in very young children and
est standard in evidence-based health care and most of in partially-erupted posterior permanent teeth [18]. However,
the Cochrane Oral Health Group reviews focus on the available evidence does not allow a denitive conclusion as
 d e n t a l m a t e r i a l s 3 2 ( 2 0 1 6 ) 323333 327

to whether glass-ionomer or resin-modied glass-ionomer resin-bonding materials, glass-ionomer cements, compomers

sealants are equally effective or superior to resin-based dental and resin-modied glass-ionomers for bonding or banding).
sealants in preventing occlusal dental caries in permanent or It should be noted that an earlier version of this review had
primary teeth [17,19]. less strict inclusion criteria and therefore included a higher
A recent mapping of systematic reviews undertaken number of studies. The updated review made substantial
for topics considered clinically relevant for the practice of changes to the protocol regarding inclusion criteria, which
Pediatric Dentistry concluded that there is high to moderate- resulted in the exclusion of all studies included previously.
quality evidence of a caries preventive effect of ssure sealing For example, quasi-randomized studies were excluded. Also,
with resin-based materials. This study also noted that there is split-mouth trials were no longer accepted as they may lead
still uncertainty concerning the effectiveness of ssure seal- to biased treatment efcacy estimates due to carry-across
ing with other materials [20]. The Cochrane review on dental effects [31]. The changes in the inclusion criteria resulted in
sealants for caries prevention that was updated and published changes in the conclusions; while the rst version concluded
in 2013 encourages conducting good quality primary studies that uoride-releasing bonding materials during orthodontic
that compare the caries protective effect of different types of treatment could reduce the occurrence and severity of white
sealants [17]. spot lesions, the updated version could not draw any conclu-
A Medline search via Pubmed using the Clinical Query sion regarding the effects of such materials due to the absence
option identied six clinical trials that evaluated the caries of studies meeting the inclusion criteria.
preventive effect of different dental sealing materials and Other Cochrane reviews have evaluated the effectiveness
were published after the date of the end of the search per- of adhesives used to attach bands or bonded molar tubes dur-
formed in the Cochrane review. These studies tested and ing xed appliance treatment on dental caries in the banded
compared the caries preventive effect of high-viscosity glass- or bonded teeth. First permanent molars where bands had
ionomer cements, uoride-releasing resin-based sealants, a been cemented with glass-ionomer developed fewer white
owable composite resin, glass carbomer sealants and an spot lesions than those where bands had been cemented with
ormocer sealant [2126]. Most of them had a split-mouth zinc phosphate. However, this evidence is considered weak
design and only two found that one material performed better as it comes from only two trials that did not perform any
than the other; the results of one study favored a high- statistical analysis [32]. Regarding the comparison between
viscosity glass-ionomer sealant over an ormocer sealant and adhesives used to attach bonded molar tubes and adhesives
those of another study favored a high-viscosity glass-ionomer used to attach bands, one trial found that participants whose
cement over a glass carbomer sealant. There is still a clear rst permanent molars had tubes bonded with light-cured
need for more clinical trials on this topic and studies aiming at composite developed more white spot lesions compared to
investigating the possible benets of local release of uoride patients whose rst permanent molars had bands cemented
from sealants should not use a split-mouth design because with glass-ionomer, although enamel changes were consid-
it has been shown that the cariostatic effect of a uoride- ered minor as they could not be seen in wet teeth [33].
releasing dental sealant can be exerted beyond the pits and One non-Cochrane review concluded that uoride-
ssures of the sealed tooth; for example, on the distal surfaces releasing bonding materials appear to have no signicant
of second primary molars adjacent to a tooth sealed with GIC effect on the prevention of white spot lesions development
[27]. [34] and another revealed weak evidence that glass-ionomer
cements might be more effective than composite resins in pre-
4.2. Bonding orthodontic materials venting white spot lesions development in xed orthodontic
patients [35].
The presence of orthodontic appliances increases the num- Finally, a search for recent RCTs in Medline via Pubmed
ber of retentive sites in the dentition and also may cause failed to nd any parallel RCT addressing the question of
pain and discomfort [28]. This makes it more difcult for indi- interest. Taken together, the evidence accrued from the sys-
viduals to properly clean their teeth, which increases biolm tematic reviews described above makes it impossible to
accumulation. Thus, orthodontic treatment carries the risk of provide any evidence-based recommendation regarding the
caries lesion development. Initial enamel lesions may develop effectiveness of using uoride-releasing material to bond or
around orthodontic appliances as early as six months after cement orthodontic appliances on white lesion spots devel-
bonding [29,30]. opment. There is a need to design high quality clinical trials
An alternative to compensate for the increased caries on this subject. Researchers should prioritize RCTs with a par-
risk would be to enhance uoride availability using uoride- allel design and use standardized methods of caries diagnosis,
releasing orthodontic adhesives or cements. These materials including the assessment of white spot lesions as well as cav-
would act as uoride reservoirs and could potentially increase itated lesions at both enamel and dentin levels. Also, studies
uoride levels in saliva, biolm and dental hard tissues. should cover longer follow-up periods in order to assess the
One Cochrane systematic review we found aimed to eval- impact of white spot lesions on patients esthetic perception
uate the effects of uoride in reducing the incidence of white and satisfaction.
spot lesions during orthodontic treatment [28]. In the updated
version of this review, three studies, among which only one 4.3. Restorative materials
had low risk of bias, met the inclusion criteria but none of
them were RCTs testing materials containing uoride that is Fluoride-releasing restorative materials are seen as very
released during treatment (e.g., uoride-releasing composite attractive to the clinician because they could serve a
328 d e n t a l m a t e r i a l s 3 2 ( 2 0 1 6 ) 323333

double purpose; besides repairing carious or defective teeth, children [40]. Placement of all restorations was preceded by the
they could help prevent the development of new carious application of a bonding agent with a uoride-release charac-
lesions. However, very few systematic reviews and clinical teristic and children in the two treatment groups also received
trials have considered the anti-caries effect of these dental uoride-releasing dental sealants. After a mean follow-up
materials as their outcome measure. period of 1.4 years, an exploratory sub-analysis of the data
In 2006, Wiegand et al. [14] reviewed existing evidence showed that the frequency of restoration replacement due to
on the cariostatic effect of uoride-releasing dental restora- caries in posterior primary teeth was signicantly higher in
tives. They found few clinical longitudinal studies with an teeth restored with compomer (3.0%) than in teeth restored
observation period of three years or more that evaluated with amalgam (0.5%). Additional analysis of data from the
the inuence of uoride-releasing dental materials on den- same trial [41] assessed whether the occurrence of new caries
tal caries development and noted that these studies showed on teeth other than the tooth where the restoration was placed
conicting results as to whether or not these materials con- varied by type of restorative material over a 5-year follow-
tribute to reduction of the risk of developing new dental caries up period. A very small, but statistically signicant effect of
lesions. dental material on new caries formed in different teeth was
A Cochrane review [36] compared survival and caries devel- found in favor of amalgam restorations; caries lesions on other
opment for restorative materials used to treat dental caries teeth appeared sooner after the placement of compomer than
lesions in childrens primary dentition. Of the three stud- after the placement of amalgam. In contrast, among restora-
ies included, two compared a uoride-releasing material to a tions with a full 5 years of follow-up, the mean number of
non-uoride releasing material. One split-mouth study com- new caries lesions on other teeth or on other surfaces of the
pared a resin-modied glass-ionomer with an amalgam over same tooth was slightly lower in children who received com-
a 36-month period, and another tested a compomer versus an pomer restorations than in children who received amalgam
amalgam. Only the 12-month data of the former and the 24- restorations. Overall, it was not possible to conclude whether
month data of the latter were useable. At 12 months no caries one material was more successful than the other in preventing
lesion was recorded and at 24 months there was no differ- dental caries.
ence between compomer and amalgam restorations in terms Glass-ionomer cements (GIC) have also been used in the
of secondary caries. atraumatic restorative treatment (ART). This technique, origi-
A systematic review published in 2009 [37] compared the nally designed for non-dental settings, has now been included
absence of caries lesions at the margins of glass-ionomer in dental curriculums and is used by private practitioners [42].
cement (GIC) and amalgam restorations in primary and The outcome measure in all systematic reviews we iden-
permanent posterior teeth. A meta-analysis combining the tied comparing ART with conventional restorations was
results of a parallel and a split-mouth study with a follow- restoration survival, that is, tooth or restoration fracture or
up of 6 years showed an odds ratio (OR) of 2.64 (95% CI 1.39, loss. One of these reviews also assessed the caries-preventive
5.03) in favor of single-surface GIC restorations in permanent effect of ART sealants, but not of ART restorations [43]. Survival
teeth. No other statistically signicant differences were found. rates of ART and conventional restorations appear to be simi-
This systematic review has been updated; ve new trials were lar [4347]. However, these similar survival rates do not answer
included and one trial that was accepted in the original review the question whether the use of a uoride-releasing material
was excluded [38]. All of the included trials appear to be sub- reduces the risk of new caries lesions. Most studies compared
jected to the risk of selection and detection/performance bias. ART to amalgam restorations and these differ not only in the
Although new estimates of effect were produced, the original restorative material employed, but also in the amount of car-
conclusions did not change and it was found that the margins ious tissue removed, the instruments used to remove it and
of single-surface GIC restorations in permanent teeth had a the preservation of remaining tooth structure.
65% lower chance of developing carious lesions after 6 years A recent parallel RCT comparing amalgam restorations
than did similar teeth restored with amalgam (RR 0.35; 95% CI and ART with a high-viscosity GIC in primary molars showed
0.19, 0.65). that few restorations (5.4%) failed due to dentin caries along-
Another systematic review sought to verify whether side the restoration. After three years, both materials showed
resin-modied glass-ionomer cements (RM-GIC) offer a more higher survival rates when used in single-surface restorations
signicant caries-preventive effect than composite resins (CR) and no signicant difference was found between the cumula-
[39]. Four studies addressing dental restorations in children tive survival rates of amalgam and ART restorations. It should
or in adult patients who had received radiation therapy to be noted that the high-viscosity GIC was used with a higher
the head and neck were included. There was substantial than usual powder-to-liquid ratio [48].
heterogeneity among the studies and no meta-analysis was Besides the lack of assessment of caries as an out-
performed. Most of the comparisons made provided no sta- come measure, the systematic reviews mentioned above
tistically signicant differences in terms of caries protection have other limitations: the rst studies of ART used low or
between the two materials. Moreover, all studies presented medium-viscosity GIC, whereas more recent ones have used
methodological problems that could compromise their inter- high-viscosity GIC, which has been the type of GIC required
nal validity. Therefore, no conclusion regarding the review with ART since the mid-1990s; there are few long-term studies
question could be drawn. available; most studies focused on primary teeth, which have
The search for parallel RCTs in Medline via Pubmed iden- a shorter lifespan; there is a high risk of bias in the included
tied one study that investigated the longevity of amalgam studies, especially due to the inclusion of uncontrolled lon-
and compomer restorations in primary molars of 610 year old gitudinal clinical studies or RCTs with unclear randomized
 d e n t a l m a t e r i a l s 3 2 ( 2 0 1 6 ) 323333 329

Table 2 Summary of clinical studies about uoride-releasing materials.

Type of dental material Systematic reviews RCT Conclusions
Pit and ssure sealants Mejare et al., 2003 Chen and Liu, 2013 Fissure sealing with resin-based
Chadwick et al., 2005 Guler and Yilmaz, 2013 materials has a caries preventive
Ahovuo-Saloranta et al., 2013 Erdemir et al., 2014 effect. It is still not known whether
Mejare et al., 2015 Gorset et al., 2014 F-releasing resin-based sealants
Liu et al., 2014 provide any additional benet. There
Zhang et al., 2014 is still uncertainty concerning the
effectiveness of ssure sealing with
other materials.

Bonding orthodontic materials Derks et al., 2004 None The evidence on the effectiveness of
Millet et al., 2007 using F-releasing material to bond or
Rogers et al., 2010 cement orthodontic appliances on
Millet et al., 2011 white lesion spots development is still
Benson et al., 2013 inconclusive.

Restorative materials Frencken et al., 2004 Socini et al., 2007 It is still not known whether
Vant Hof et al., 2006 Trachtenberg et al., 2009 F-releasing restoratives reduce caries
Wiegand et al., 2007 Hilgert et al., 2014 risk in comparison to non F-releasing
Yengopal et al., 2009 restoratives. There is weak evidence
Mickenaustsch et al., 2009 that GIC confers greater caries
Mickenaustsch et al., 2010 protection than amalgam in
Mickenaustsch and Yengopal, 2011 single-surface restorations in
Yengopal and Mickenaustsch, 2011 permanent teeth.
Mickenaustsch and Yengopal, 2012

sequence allocation and/or allocation concealment; and pub- sometimes they are the best available evidence [51,52]. In fact,
lication bias cannot be ruled out due to language and database in order to minimize potential differences between the results
searching restrictions. of a clinical trial and those obtained from in vitro and in situ
These shortcomings may be addressed in a planned studies, models have been developed and validated aiming
Cochrane review that aims to assess the effects of ART for to simulate what occurs in real life. Nevertheless, models are
the treatment of decayed primary and permanent teeth in only models and we have to be careful to choose the one(s)
children and adults. In the published protocol, the authors that best mimics clinical performance.
stated that non-randomized studies will be excluded; other
outcomes, in addition to restoration failure, such as caries, will
be considered; all included trials will be evaluated regarding 5.1. Evaluation of uoride release from dental
the potential of bias; and a comprehensive search will be per- materials
formed [49].
In conclusion, it is still not known whether uoride- When testing uoride-releasing dental materials, our mod-
releasing restoratives reduce caries risk in comparison to els should simulate the caries process as closely as possible
non uoride-releasing restoratives and there is only weak to correctly estimate the anti-caries potential of those mate-
evidence that GIC confers greater caries protection than amal- rials. Even the simplest test, such as the one that assesses
gam in single-surface restorations in permanent teeth. It the ability of a material to release uoride, should simulate
seems that there is an urgent need for well-designed, random- the caries process, because uoride controls caries lesions
ized controlled trials to investigate the anti-caries benet of progression by reducing demineralization when the pH drops
uoride-releasing lling materials. In order to provide results and by enhancing remineralization when the pH rises again
that can be used to positively inuence clinical practice, future [5355]. An incorrect simulation of uoride release, ignoring
trials should adhere to the CONSORT guidelines [50], adopt how uoride works on caries control, has implications not only
a parallel group design [38] and report on outcomes that are to estimate the anti-caries potential of the material but also to
important to both clinicians and patients. compare different commercial products, as shown in Table 3.
In summary (Table 2), if uoride releasing materials are Thus, if water is used to estimate the release, the best product
clinically effective on caries control is still a dogma but based is the rst of the table, but if the caries process is simulated
on large numbers of in vitro and in situ studies made, they by cycling the specimens in de- and remineralizing solutions,
should work; this will be discussed in the next section of this the best product would be the second one. Moreover, data on
paper. cumulative release are not relevant to control caries, since it
is a chronic disease and the process of caries lesions progres-
sion occurs every day, every time. Thus, uoride should be
5. Anti-caries potential of uoride constantly available in the mouth to interfere with the caries
releasing materials in vitro and in situ studies process. Consequently, the release should be evaluated for
long periods because uoride does not work as a vaccine and,
No result from in vitro or in situ studies can be directly extrap- therefore, it does not strengthen the tooth. Fluoride release
olated to the clinical situation without further testing, but should be evaluated in real time.
330 d e n t a l m a t e r i a l s 3 2 ( 2 0 1 6 ) 323333

Table 3 Fluoride released (g F/cm2 ) from dental materials to different media. Carvalho and Cury, 1999.
Materials Media

H2 O Articial saliva pH-cycling

deremineralizing
solutions
CHE 7.62 0.73 A 1.26 0.08 B 8.35 0.51 B
VIT 5.91 0.79 B 3.13 0.36 A 12.27 1.16A
VAR 2.71 0.25 C 0.80 0.10 C 6.17 0.24 D
DYR 1.50 0.17 D 1.20 0.05 B 7.82 0.65 C
TET 0.14 0.02 E 0.07 0.003 D 0.28 0.02 E
Materials followed by distinct letter differ from each other.

5.2. Evaluating the effect of the uoride released 5.3. Evaluating in situ the effect of uoride-releasing
in vitro pH-cycling chemical model materials

Fluoride works interfering with the dynamics of the caries pro- In situ models can be used to evaluate the physicochemical
cess and therefore the effect of uoride-releasing materials effect of uoride on caries process and also some antibac-
should be tested using models that mimic the caries process terial effect of the material, if present [5,65]. The necessary
[56]. If the material releases only uoride, its effect can be biolm accumulation is provided and the biolms are exposed
evaluated using simple pH-cycling chemical models because to sugar several times a day, simulating a high cariogenic chal-
the antimicrobial effect of uoride on caries is not relevant. lenge.
Fluoride only has an effect on the metabolism of bacteria at The main outcome in this kind of study is the reduction
concentrations of 10 ppm or higher [57], and no way or vehi- of demineralization [65]. Fluoride uptake by enamel or dentin
cle of uoride use is able to sustain this concentration in can be determined to give support to the demineralization
biolm [5,9,13,5860]. However, if the uoride-releasing mate- ndings found and to explain how uoride works reducing
rial releases any antibacterial substance, its synergistic or caries lesion progression adjacent to the lling or any dental
additive effect with uoride should be evaluated using in vitro surface.
biolm models [61] or an in situ protocol [5,62].pH-cycling When the potential antibacterial effect of a given dental
chemical models are the ones most used to test dental mate- material is to be tested, in situ models or biolm models can
rials and they are useful to compare the effect of a restorative be used. Although the antibacterial effect of uoride is not
or bonding uoride-releasing material with that of a negative clinically relevant, it could be enhanced by other ions simulta-
control material that does not release uoride. The effect of neously released from the material, such as aluminum. Using
uoride-releasing materials on the reduction of demineral- an in vitro biolm model, we found promising results on the
ization on enamel or dentin adjacent to llings and bondings combined effect of F and Al [61]. However, this evaluation was
tested in a pH-cycling model can be assessed qualitatively (e.g. done using a closed in vitro model and our mouth is an open
visual inspection of the nal aspects of restored slabs) and sink that does not concentrate the cumulative effect of ions
quantied using validated methods to estimate mineral loss released from dental materials. In two other in situ studies
[56]. aiming to check the promising results found in vitro for the
However, in vitro pH-cycling models should not be used combined effect of F and Al [62,66], enamel blocks restored
to compare different uoride-releasing materials because with a composite resin as negative control, with a material
there is no pH-cycling model validated to differentiate their that releases mainly uoride (Ketac Fil ), or with one that
doseresponse effect. Indeed, the effect of uoride-releasing releases high amounts of Al and F (Vitremer ) were submit-
materials has been evaluated using models that have been ted to cariogenic challenges to test the anti-caries effect of
developed to evaluate uoride dentifrice and very few of them the materials. In the short term in situ study [62], restored
were validated in terms of dose-response [63,64]. enamel slabs were placed in contact with a culture of Strepto-
Moreover, since uoride works interfering with the de- coccus mutans in palatal appliances worn by volunteers. They
remineralization process and not by making tooth minerals rinsed with a 20% sucrose solution for 1 min as a cariogenic
more resistant to acids, there is no reason to assess uoride challenge and the effect of the restorative material was evalu-
uptake by enamel or dentin as an important outcome mea- ated by microhardness change in enamel. The results showed
sure to explain the mode of action of uoride-releasing dental that both uoride-releasing materials reduced demineraliza-
materials [65]. This outcome represents only the consequence tion around the llings in comparison with resin, but we could
of caries progression reduction by uoride availability. In fact, not nd differences between the two uoride-releasing mate-
the higher concentration of uoride found in enamel adjacent rials being evaluated.
to an ionomeric lling in comparison with resin is not due to a Fluoride concentration in biolm and in enamel adjacent to
chemical reaction between uoride released and enamel, but the llings was tested, indicating that the materials released
to the effect of uoride on the caries process (Fig. 2a and b). uoride to the biolm, which was then taken up by enamel
 d e n t a l m a t e r i a l s 3 2 ( 2 0 1 6 ) 323333 331

Fig. 3 Fluoride concentration (M) in the uid of biolm

formed on to cervical enamel/dentin slabs restored with
composite resin or glass-ionomer cement (GIC), under
non-F or F dentifrice use. Fluoride present on the biolm
formed on glass ionomer cement restorations (around
5 M = 0.1 ppm F) represent 1/100 of the necessary
concentration to present antibacterial activity, Cenci et al.
[5].

during the cariogenic challenge, with no difference between

the two materials [62].
In a subsequent long-term in situ study to test the same
materials, the effect of uoride was conrmed, but not the
additive effect of aluminum [66].
Fig. 4 Area of mineral loss (vol.% mineral m) on the
5.4. Combined effect of uoride from dental materials enamel (a) or dentin (b) margins of composite or
and dentifrice in situ glass-ionomer restorations exposed to a high cariogenic
challenge in situ, under the use of non-F or F dentifrice,
In situ studies can also be used to estimate the combined effect Cenci et al. [5].
of uoride released by a lling and that delivered by dentifrice.
An in situ study to test the effect of this combination [67] found
that a uoride releasing material could be dispensable if uo-
ride dentifrice was being used. However, appropriate controls material itself has the property to release uoride at a concen-
are mandatory and the study lacked a control group testing tration effective to control caries, either in enamel or in dentin
a negative control lling material (composite resin), under (Fig. 4). However, no additive or synergistic effect was observed
non-uoride dentifrice use. A following study [5] designed to when uoride dentifrice was concomitantly used 3/day.
overcome this limitation tested the effect of glass-ionomer Unfortunately, the data of this crossover in situ study
cement restorations (against an appropriate negative control cannot be validated by a clinical trial, because no ethical
using composite resin) on the inhibition of mineral loss adja- committee would approve a non-uoride dentifrice group.
cent to enamel or dentin, under the use of uoride dentifrice Therefore, it will remain as the best evidence available to rec-
(against an appropriate negative control using non uoride ommend the use of uoride-releasing restorative materials in
dentifrice). The biolms formed on the restored slabs were patients with low adherence to uoride dentifrice use, but at
analyzed for biochemical and microbiological composition, the same time to make them unnecessary in patients who use
and demineralization adjacent to the cervical restoration was uoride dentifrice regularly.
assessed on the enamel and dentin margins using transverse
microradiography.
Biolm uid was separated from the solids and for the rst 6. Conclusions
time uoride released by dental material was quantied in
biolm uid; the right place where uoride should be present In summary, dental caries is not a result of uoride deciency
to interfere with the caries process. The results showed that but uoride frequently available in the oral environment can
uoride concentration is 100 times lower than that needed for effectively slow down the rate of lesion progression in every
the uoride-releasing material to present antibacterial action dental surface where biolm is accumulated and regularly
(Fig. 3). exposed to dietary sugars.
Regarding demineralization, the results clearly showed Since caries is a biolm-sugar dependent disease, daily
that in the absence of uoride from dentifrice, the dental oral hygiene, preferably with uoride dentifrice, and the
332 d e n t a l m a t e r i a l s 3 2 ( 2 0 1 6 ) 323333

restriction of the intake of dietary carbohydrates are manda- [17] Ahovuo-Saloranta A, Forss H, Walsh T, Hiiri A, Nordblad A,
tory to achieve maximum caries control. Makela M, et al. Sealants for preventing dental decay in the
Fluoride-releasing dental materials present the necessary permanent teeth. Cochrane Database Syst Rev
2013;3:CD001830.
properties to be effective on caries control. However, their
[18] Uribe S. No evidence to support use of glass ionomer as a
effectiveness to control caries is not still proved. Also, the ssure sealant in primary molars. Evid Based Dent 2005;6:35.
effect of uoride released by dental materials on caries can [19] Chadwick BL, Treasure ET, Playle RA. A randomised
be substituted by uoride delivered from dentifrice. controlled trial to determine the effectiveness of glass
ionomer sealants in pre-school children. Caries Res
2005;39:3440.
[20] Mejare IA, Klingberg G, Mowa FK, Stecksen-Blicks C,
references
Twetman SH, Tranaeus SH. A systematic map of systematic
reviews in pediatric dentistry what do we really know?
PLOS ONE 2015;10:e0117537.
[1] Fejerskov O. Changing paradigms in concepts on dental [21] Gorseta K, Glavina D, Borzabadi-Farahani A, Van Duinen RN,
caries: consequences for oral health care. Caries Res Skrinjaric I, Hill RG, et al. One-year clinical evaluation of a
2004;38:18291. Glass Carbomer ssure sealant, a preliminary study. Eur J
[2] Sheiham A, James WP. Diet and dental caries: the pivotal Prosthodont Restor Dent 2014;22:6771.
role of free sugars reemphasized. J Dent Res 2015;94:13417. [22] Erdemir U, Sancakli HS, Yaman BC, Ozel S, Yucel T, Yildiz E.
[3] Marsh PD. Dental diseases are these examples of Clinical comparison of a owable composite and ssure
ecological catastrophes? Int J Dent Hyg 2006;4(Suppl 1):310, sealant: a 24-month split-mouth, randomized, and
discussion 50-2. controlled study. J Dent 2014;42:14957.
[4] Paes Leme AF, Koo H, Bellato CM, Bedi G, Cury JA. The role of [23] Guler C, Yilmaz Y. A two-year clinical evaluation of glass
sucrose in cariogenic dental biolm formation new insight. ionomer and ormocer based ssure sealants. J Clin Pediatr
J Dent Res 2006;85:87887. Dent 2013;37:2637.
[5] Cenci MS, Tenuta LM, Pereira-Cenci T, Del Bel Cury AA, ten [24] Chen X, Liu X. Clinical comparison of Fuji VII and a resin
Cate JM, Cury JA. Effect of microleakage and uoride on sealant in children at high and low risk of caries. Dent Mater
enameldentine demineralization around restorations. J 2013;32:5128.
Caries Res 2008;42:36979. [25] Zhang W, Chen X, Fan MW, Mulder J, Huysmans MC,
[6] Cenci MS, Pereira-Cenci T, Cury JA, Ten Cate JM. Relationship Frencken JE. Do light cured ART conventional high-viscosity
between gap size and dentine secondary caries formation glass-ionomer sealants perform better than resin-composite
assessed in a microcosm biolm model. Caries Res sealants: a 4-year randomized clinical trial. Dent Mater
2009;43:97102. 2014;30:48792.
[7] Fejerskov O, Cury JA, Tenuta LMA, Marinho V. Fluorides in [26] Liu BY, Xiao Y, Chu CH, Lo EC. Glass ionomer ART sealant
caries control. In: Fejerskov O, Kidd E, editors. Dental caries: and uoride-releasing resin sealant in ssure caries
the disease and its clinical management. third ed. Oxford: prevention results from a randomized clinical trial. BMC
Wiley Blackwell; 2015. p. 24576. Oral Health 2014;14:54.
[8] Cury JA, Tenuta LM. Enamel remineralization: controlling [27] Cagetti MG, Carta G, Cocco F, Sale S, Congiu G, Mura A, et al.
the caries disease or treating early caries lesions? Braz Oral Effect of uoridated sealants on adjacent tooth surfaces: a
Res 2009;23(Suppl 1):2330. 30-mo randomized clinical trial. J Dent Res 2014;93:59S65S.
[9] Tenuta LM, Cury JA. Fluoride: its role in dentistry. Braz Oral [28] Benson PE, Parkin N, Dyer F, Millett DT, Furness S, Germain P.
Res 2010;24(Suppl 1):917. Fluorides for the prevention of early tooth decay
[10] Marinho VC, Higgins JP, Sheiham A, Logan S. Combinations (demineralised white lesions) during xed brace treatment.
of topical uoride (toothpastes, mouthrinses, gels, Cochrane Database Syst Rev 2013;12:CD003809.
varnishes) versus single topical uoride for preventing [29] Tufekci E, Dixon JS, Gunsolley JC, Lindauer SJ. Prevalence of
dental caries in children and adolescents. Cochrane white spot lesions during orthodontic treatment with xed
Database Syst Rev 2004;(1). Art. No.: CD002781. appliances. Angle Orthod 2011;81:20610.
[11] Tenuta LM, Zamataro CB, Del Bel Cury AA, Tabchoury CP, [30] Lucchese A, Gherlone E. Prevalence of white-spot lesions
Cury JA. Mechanism of uoride dentifrice effect on enamel before and during orthodontic treatment with xed
demineralization. Caries Res 2009;43:27885. appliances. Eur J Orthod 2013;35:6648.
[12] Vieira AR, de Souza IP, Modesto A. Fluoride uptake and [31] Hujoel PP. Design and analysis issues in split mouth clinical
release by composites and glass ionomers in a high caries trials. Community Dent Oral Epidemiol 1998;26:856.
challenge situation. Am J Dent 1999;12:148. [32] Millett DT, Glenny AM, Mattick CR, Hickman J, Mandall NA.
[13] Paes Leme AF, Dalcico R, Tabchoury CP, Del Bel Cury AA, Adhesives for xed orthodontic bands. Cochrane Database
Rosalen PL, Cury JA. In situ effect of frequent sucrose Syst Rev 2007:CD004485.
exposure on enamel demineralization and on plaque [33] Millett DT, Mandall NA, Mattick RC, Hickman J, Glenny AM.
composition after APF application and F dentifrice use. J Adhesives for bonded molar tubes during xed brace
Dent Res 2004;83:715. treatment. Cochrane Database Syst Rev 2011:CD008236.
[14] Wiegand A, Buchalla W, Attin T. Review on uoride-releasing [34] Derks A, Katsaros C, Frencken JE, vant Hof MA,
restorative materials uoride release and uptake Kuijpers-Jagtman AM. Caries-inhibiting effect of preventive
characteristics, antibacterial activity and inuence on caries measures during orthodontic treatment with xed
formation. Dent Mater 2007;23:34362. appliances. A systematic review. Caries Res 2004;38:41320.
[15] Smail-Faugeron V, Fron-Chabouis H, Courson F. [35] Rogers S, Chadwick B, Treasure E. Fluoride-containing
Methodological quality and implications for practice of orthodontic adhesives and decalcication in patients with
systematic Cochrane reviews in pediatric oral health: a xed appliances: a systematic review. Am J Orthod Dentofac
critical assessment. BMC Oral Health 2014;14:35. Orthop 2010;138:390, e18; discussion-1.
[16] Mejare I, Lingstrom P, Petersson LG, Holm AK, Twetman S, [36] Yengopal V, Harneker SY, Patel N, Siegfried N. Dental llings
Kallestal C, et al. Caries-preventive effect of ssure sealants: for the treatment of caries in the primary dentition.
a systematic review. Acta Odont Scand 2003;61:32130. Cochrane Database Syst Rev 2009:CD004485.
 d e n t a l m a t e r i a l s 3 2 ( 2 0 1 6 ) 323333 333

[37] Mickenautsch S, Yengopal V, Leal SC, Oliveira LB, Bezerra AC, [51] ten Cate JM. Models and role models. Caries Res
Bonecker M. Absence of carious lesions at margins of 2015;49(Suppl 1):310.
glass-ionomer and amalgam restorations: a meta-analysis. [52] Zero DT. In situ caries models. Adv Dent Res 1995;9:21430,
Eur J Paediatr Dent 2009;10:416. discussion 31-4.
[38] Mickenautsch S, Yengopal V. Absence of carious lesions at [53] Hayacibara MF, Ambrozano GM, Cury JA. Simultaneous
margins of glass-ionomer cement and amalgam release of uoride and aluminum from dental materials in
restorations: an update of systematic review evidence. BMC various immersion media. Oper Dent 2004;29:1622.
Res Notes 2011;4:58. [54] Cury JA, Saad J, Rodrigues Junior A. Fluoride release from
[39] Yengopal V, Mickenautsch S. Caries-preventive effect of sealant in water, saliva and demineralizingremineralizing
resin-modied glass-ionomer cement (RM-GIC) versus solutions. Rev Gaucha Odont 1993;41:2735 [in Portuguese].
composite resin: a quantitative systematic review. Eur Arch [55] Carvalho AS, Cury JA. Fluoride release from some dental
Paediatr Dent 2011;12:514. materials in different solutions. Oper Dent 1999;24:149.
[40] Soncini JA, Maserejian NN, Trachtenberg F, Tavares M, Hayes [56] Serra MC, Cury JA. The in vitro effect of glass-ionomer
C. The longevity of amalgam versus compomer/composite cement restoration on enamel subjected to a
restorations in posterior primary and permanent teeth: demineralization and remineralization model. Quintessence
ndings From the New England Childrens Amalgam Trial. J Int 1992;23:1437.
Am Dent Assoc 2007;138:76372. [57] Bradshaw DJ, Marsh PD, Hodgson RJ, Visser JM. Effects of
[41] Trachtenberg F, Maserejian NN, Soncini JA, Hayes C, Tavares glucose and uoride on competition and metabolism within
M. Does uoride in compomers prevent future caries in in vitro dental bacterial communities and biolms. Caries
children? J Dent Res 2009;88:2769. Res 2002;36:816.
[42] Frencken JE, Leal SC, Navarro MF. Twenty-ve-year [58] Nobre dos Santos M, Cury JA. Dental plaque uoride is lower
atraumatic restorative treatment (ART) approach: a after discontinuation of water uoridation. Caries Res
comprehensive overview. Clin Oral Investig 2012;16: 1988;22:3167.
133746. [59] Cury JA, do Amaral RC, Tenuta LM, Del Bel Cury AA,
[43] de Amorim RG, Leal SC, Frencken JE. Survival of atraumatic Tabchoury CP. Low-uoride toothpaste and deciduous
restorative treatment (ART) sealants and restorations: a enamel demineralization under biolm accumulation and
meta-analysis. Clin Oral Investig 2012;16:42941. sucrose exposure. Eur J Oral Sci 2010;118:3705.
[44] Frencken JE, Van t Hof MA, Van Amerongen WE, Holmgren [60] Vale GC, Tabchoury CP, Del Bel Cury AA, Tenuta LM, ten Cate
CJ. Effectiveness of single-surface ART restorations in the JM, Cury JA. APF and dentifrice effect on root dentin
permanent dentition: a meta-analysis. J Dent Res demineralization and biolm. J Dent Res 2011;90:7781.
2004;83:1203. [61] Hayacibara MF, Rosa OP, Koo H, Torres SA, Costa B, Cury JA.
[45] van t Hof MA, Frencken JE, van Palenstein Helderman WH, Effects of uoride and aluminum from ionomeric materials
Holmgren CJ. The atraumatic restorative treatment (ART) on S. mutans biolm. J Dent Res 2003;82:26771.
approach for managing dental caries: a meta-analysis. Int [62] Tenuta LM, Ribeiro CC, Goncalves NC, Del Bel Cury AA, Aires
Dent J 2006;56:34551. CP, Tengan C, et al. The short-term in situ model to evaluate
[46] Mickenautsch S, Yengopal V, Banerjee A. Atraumatic the anticariogenic potential of ionomeric materials. J Dent
restorative treatment versus amalgam restoration longevity: 2005;33:4917.
a systematic review. Clin Oral Investig 2010;14:23340. [63] Vieira AE, Delbem AC, Sassaki KT, Rodrigues E, Cury JA,
[47] Mickenautsch S, Yengopal V. Failure rate of atraumatic Cunha RF. Fluoride dose response in pH-cycling models
restorative treatment using high-viscosity glass-ionomer using bovine enamel. Caries Res 2005;39:51420.
cement compared to that of conventional amalgam [64] Queiroz CS, Hara AT, Paes Leme AF, Cury JA. pH-cycling
restorative treatment in primary and permanent teeth: a models to evaluate the effect of low uoride dentifrice on
systematic review update. JMID 2012;5:63124. enamel de- and remineralization. Braz Dent J 2008;19:217.
[48] Hilgert LA, de Amorim RG, Leal SC, Mulder J, Creugers NH, [65] Benelli EM, Serra MC, Rodrigues Jr AL, Cury JA. In situ
Frencken JE. Is high-viscosity glass-ionomer-cement a anticariogenic potential of glass ionomer cement. Caries Res
successor to amalgam for treating primary molars? Dent 1993;27:2804.
Mater 2014;30:11728. [66] Tabchoury CP, Dalcico R, Del Bel Cury AA, Rosalen PL, Cury
[49] Dorri M, Sheiham A, Marinho VCC. Atraumatic restorative JA. In situ anticariogenic potential of conventional and
treatment versus conventional restorative treatment for the resin-modied glass ionomer cement. J Dent Res 2002;81.
management of dental caries. Cochrane Database Syst Rev Spec Iss B, Abstr. No. 26.
2009. Art. No.: CD008072. [67] Hara AT, Turssi CP, Ando M, Gonzalez-Cabezas C, Zero DT,
[50] Schulz KF, Altman DG, Moher D. CONSORT 2010 statement: Rodrigues Jr AL, et al. Inuence of uoride-releasing
updated guidelines for reporting parallel group randomised restorative material on root dentine secondary caries in situ.
trials. PLoS Med 2010;7:e1000251. Caries Res 2006;40:4359.