Caries prevention in children: Fluoride varnishes or sealants?

Fissure sealant

Caries is one of the worlds commonest diseases affecting populations worldwide. Although it is a largely preventable disease it has been estimated that the direct costs of providing dental care consume approximately 5% of the global health budget.  Reviews have demonstrated that both fissure sealants and fluoride varnishes are effective in caries prevention in children and adolescents.

The aim of this Cochrane review update was to evaluate the relative effectiveness of dental sealants (i.e. fissure sealant) compared with fluoride varnishes, or fissure sealants plus fluoride varnishes compared with fluoride varnishes alone, for preventing dental caries in the occlusal surfaces of permanent teeth of children and adolescents.


Searches were conducted in the Cochrane Oral Health’s Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, the US National Institutes of Health Trials Registry ( and the World Health Organization International Clinical Trials Registry Platform with no restrictions on the language or date of publication. Randomised controlled trials (RCTs) comparing fissure sealants, or fissure sealants plus fluoride varnishes, versus fluoride varnishes for caries prevention in the occlusal surfaces of permanent posterior teeth with at least 12 months follow up were considered.  Independent selection of studies, data abstraction and risk of bias assessment using the Cochrane tool was carried out by two reviewers. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. The Becker-Balagtas method was used for the split mouth studies to facilitate meta-analysis.  For continuous data mean differences (MD) and 95%CI were used.  The certainty of the evidence using GRADE criteria and brief economic commentary was included.


  • 11 RCTs involving a total of 3374 patients were included.
  • All studies were considered to be at high overall risk of bias because of they were unable to undertake blind outcome assessment.

Resin-based fissure sealants versus fluoride varnishes (7 RCTs-5 providing data)

  • For preventing caries in first permanent molars at 2-3 years’ it is uncertain if resin-based sealants are better than fluoride varnish, or vice versa; OR = 0.67 (95%CI; 0.37 to 1.19) [4 studies, 1683 children].
  • One study measuring decayed, missing and filled permanent surfaces (DMFS) and teeth (DMFT) increment at two years suggested a small benefit for fissure sealant which may not be clinically significant: –
    • DMFS MD = –0.09 (95%CI; –0.15 to –0.03)
    • DMFT MD = –0.08 (95%CI; –0.14 to –0.02)
  • One small study, at high risk of bias, reported a benefit in preventing caries for sealant after:
    • 4 yrs. RR = 0.42 (95%CI; 0.21 to 0.84) [75 children) and at
    • 9 yrs. RR = 0.48, 95% CI 0.29 to 0.79; 75 children)
    • Both results having very low certainty.

Glass ionomer-based sealants versus fluoride varnishes (3 RCTs)

  • In general, the studies found no benefit of one intervention over another at one, two and three years, although one study, which also included oral health education, suggested a benefit from sealants over varnish for children at high risk of caries. (very low certainty evidence).

Sealant plus fluoride varnish versus fluoride varnish alone

  • One split-mouth trial (92 children) at two-year follow-up found in favour of resin-based fissure sealant plus fluoride varnish over fluoride varnish only OR = 0.30 (95%CI; 0.17 to 0.55). This represents a clinically meaningful 77% reduction in caries after 2 years; however, the evidence is of very low certainty.

Adverse events

  • 5 RCTs (1801 patients) reported that no adverse events resulted from use of sealants or fluoride varnishes over one to nine years.


The authors concluded: –

Applying fluoride varnish or resin-based fissure sealants to first permanent molars helps prevent occlusal caries, but it has not been possible in this review to reach reliable conclusions about which one is better to apply. The available studies do not suggest either intervention is superior, but we assessed this evidence as having very low certainty. We found very low-certainty evidence that placing resin-based sealant as well as applying fluoride varnish works better than applying fluoride varnish alone. Fourteen studies are currently ongoing and their findings may allow us to draw firmer conclusions about whether sealants and varnish work equally well or whether one is better than the other.


Systematic reviews have demonstrated the effectiveness of fissure sealants and fluoride varnishes for caries prevention in both children and adolescent. This updated Cochrane review aimed to assess the comparative effectiveness of these two widely used preventive interventions. 11 RCTs were included in the review but the currently available evidence does not indicate that one method is more effective than the other over three years.  Very low certainty evidence from one small split-mouth study did suggest that using both sealants and fluoride varnish may work better than using fluoride varnish alone.

In addition to the effectiveness element this review also included a brief economic commentary which summarised 4 economic evaluations, although these were not formally critically appraised. One UK based study that used a more rigorous methodology did indicate that fluoride varnish may achieve similar outcomes to fissure sealants at a lower cost. The authors did note that this may not be transferable to other countries health systems. The reviewers also identified 14 on-going studies which may enable firmer conclusions to be drawn in future.


Primary Paper

Kashbour W, Gupta P, Worthington HV, Boyers D. Pit and fissure sealants versus fluoride varnishes for preventing dental decay in the permanent teeth of children and adolescents. Cochrane Database of Systematic Reviews 2020, Issue 11. Art. No.: CD003067. DOI: 10.1002/14651858.CD003067.pub5.

Other references

Cochrane Oral Health Blog :-Sealants or fluoride varnishes: which treatment is better for preventing decay in the permanent back teeth of children and adolescents?

Dental Elf -20th Jan 2016

Sealants or fluoride varnish for caries prevention?

Dental Elf -31st Jul 2017

Fissure sealants effective in preventing caries in children and adolescents

Dental Elf -3rd   Jul 2019

Fluoride varnish for caries prevention in pre-school children




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Derek Richards

Derek Richards is a specialist in dental public health, Director of the Centre for Evidence-Based Dentistry and Specialist Advisor to the Scottish Dental Clinical Effectiveness Programme (SDCEP) Development Team. A former editor of the Evidence-Based Dentistry Journal and chief blogger for the Dental Elf website until December 2023. Derek has been involved with a wide range of evidence-based initiatives both nationally and internationally since 1994. Derek retired from the NHS in 2019 remaining as a part-time senior lecturer at Dundee Dental School until the end of 2023.

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