A community trial of fluoridated powdered milk in Chile

An Analytical Protocol for the Differentiation and the Potentiometric Determination of Fluorine-Containing Fractions in Bovine Milk

Free fluoride ions are effective in combating caries in children, and their supplementation in milk has been widely used worldwide for this purpose. Furthermore, it is known that ionic fluoride added to milk is distributed among its components, but little is known about their quantitative relationships. This is likely due to the absence of an analytical protocol aimed at differentiating and quantifying the most important forms of fluorine present in milk. For the first time, a comprehensive protocol made up of six potentiometric methods devoted to quantifying the most important fractions of fluorine in milk (i.e., the free inorganic fluoride, the inorganic bonded fluorine, the caseins-bonded fluorine, the whey-bonded fluorine, the lipid-bonded fluorine, and the total fluorine) has been developed and tested on real samples. Four of the six methods of the procedure are original, and all have been validated in terms of limit of detection and quantification, precision, and trueness. The data obtained show that 9% of all fluorine was in ionic form, while 66.3% of total fluorine was bound to proteins and lipids, therefore unavailable for human absorption. Beyond applications in dental research, this protocol could be extended also to other foods, or used in environmental monitoring.

Economic Evaluations of Preventive Interventions for Dental Caries and Periodontitis: A Systematic Review

OBJECTIVES

To critically examine the methods used for full economic evaluations of preventive interventions for dental caries and periodontitis.

METHODS

Published literature post-2000 was searched to April 2021. Based on a developed intervention classification framework for dental caries and periodontitis, only universal, selective or indicated interventions were included in this review. The Drummond 10-point checklist was used for quality appraisal.

RESULTS

Of 3,007 unique records screened for relevance, 73 studies were reviewed. Most model-based studies (61/73) used cost-effectiveness analysis (49%) or cost-benefit analysis (28%). Trial-based studies (16/73) commonly used cost-effectiveness analysis (59%). Four studies used both economic evaluation methods. Sixty-four papers (88%) were on dental caries, eight papers (11%) focused on periodontitis, and one paper (1%) included both oral diseases; 72% of model-based and 82% of trial-based studies were of good quality. The most frequently investigated dental caries preventive interventions were water fluoridation (universal intervention; cost-saving or cost-effective), fissure sealant and fluoride varnish (selective and indicated interventions; cost-effectiveness outcomes were inconsistent). Supportive periodontal therapy with oral health education (indicated intervention; cost-effective) was the most frequently evaluated preventive intervention for periodontitis. Thirty percent of studies with a time horizon > 1 year did not apply an appropriate discount rate and 26% did not comprehensively discuss other important considerations beyond the technical analysis.

CONCLUSIONS

Generic health outcome measures should be incorporated for economic evaluations on preventive interventions for dental caries and periodontitis, and an increased focus to prevent periodontitis using economic evaluation methods is needed to inform resource allocation and policy decision-making.

A Scopus-Based Bibliometric Analysis of Global Research Contributions on Milk Fluoridation

Fluoridated-milk schemes have been developed and implemented in many countries to prevent dental caries. This study aimed to evaluate the impact/influence of scientific publications, researchers, and institutions conducting research on milk fluoridation; to explore the international and inter-institutional collaboration and illustrate scientific output trends; and to pinpoint research hotspots in milk fluoridation research. This bibliometric analysis of original research articles on milk fluoridation includes all of the original articles published in peer-reviewed journals systematically extracted from the SCOPUS database. In total, 108 articles were included in this study, with a total of 11,789 citations. A majority (67.6%) of these articles were in the subject area of ‘dentistry’, 22.2% externally funded, 14.8% published in the journal, Caries Research, 7.4% authored/co-authored by Twetman S, 6.5% by authors from Universidad de Chile, and the UK had the highest output (24.1%). The network visualizations showed that those countries with current/past histories of implemented milk fluoridation programs were interconnected on the network visualization map, and they were predominantly the hotspots for original research on milk fluoridation. This study also identified inequalities in research outputs on the topic. With the current enormous global burden of dental caries in children, particularly in low- and middle-income countries, there is an urgent need for greater and more equitable funding of milk fluoridation research globally.

The effect of professional fluoride application program for preschool children in Taiwan: An analysis using the National Health Insurance Research Database (NHIRD)

Background/Purpose

Dental caries in primary dentition is a major public health problem in many countries, as well as Taiwan. The service of professional topical fluoride application for children under 5 years of age, performed twice a year by the BNHI in Taiwan through the “Preventive Dental Health Service for Children” plan, began in July 2004. The purpose of this study was to examine the effect and trend of professional topical fluoride application on dental utilization.

Materials and methods

The sample subjects were taken from the Normalized Million People File of 2010 in the National Health Insurance Research Database from 2000 to 2012, for the purpose of analyzing the status of the professional topical fluoride program. The main analysis included utilization of professional topical fluoride application, utilization of restorative treatment and utilization of endodontic therapy in children 1-to-5-years of age. The Cochran–Armitage trend test was used for statistical analysis.

Results

Professional topical fluoride utilization increased year upon year, particularly after 2012 (P < .001). There was a tendency to reduce the utilization of endodontic therapy (P < .001). The severity of dental caries (number of times receiving dental restoration or endodontic therapy) was decreased after professional topical fluoride application was performed (P < .001).

Conclusion

Because the dental caries rate for preschool children in Taiwan remains high, it is beneficial to receive professional topical fluoride application for dental care, as this reduces the severity of dental caries and endodontic therapy needs.

The effect on dental enamel of the frequency of consumption of fluoridated milk with a cariogenic challenge in situ

OBJECTIVES

To evaluate the effect on enamel of varying the frequency of consumption of 1.0 mg F in milk once per day, twice per day or once every other day under cariogenic challenge in situ.

MATERIALS AND METHODS

In a controlled, randomised, cross-over, single-blind study, 25 subjects wore an intra-oral lower removable appliance with enamel slabs for 21 days during each study arm. Subjects used F-free toothpaste, the cariogenic challenge comprising of five 2 min dippings per day in a 12% sucrose solution. Subjects dipped the appliances in 50 ml of 5.0 ppm fluoridated milk for five minutes during the test period once per day, twice per day, and once every other day and drank 200 ml of the same milk, once per day, twice per day (100 ml each time), or once every other day (200 ml) immediately on re-inserting their appliance in order to replicate topical and systemic effects. Slabs were analysed with surface microhardness (SMH) for protection against further demineralisation and transverse microradiography (TMR) to assess changes in mineralisation.

RESULTS

Using SMH, 200 ml of 5.0 ppm F milk once per day was significantly better than 100 ml of 5.0 ppm F twice/day (p < 0.05) and 200 ml once every other day, but not significantly. Using TMR there was a statistically significant difference in mineral loss of enamel between baseline and treatment for all groups, but not between groups.

CONCLUSIONS

Drinking 200 ml of 5.0 ppm milk once per day every day protected enamel against further demineralisation whereas all three frequencies were effective in promoting remineralisation.

Fluoridated milk for preventing dental caries

BACKGROUND

Dental caries remains a major public health problem in most industrialised countries, affecting 60% to 90% of schoolchildren and the vast majority of adults. Milk may provide a relatively cost-effective vehicle for fluoride delivery in the prevention of dental caries. This is an update of a Cochrane review first published in 2005.

OBJECTIVES

To assess the effects of milk fluoridation for preventing dental caries at a community level.

SEARCH METHODS

We searched the Cochrane Oral Health Group Trials Register (inception to November 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2014, Issue 10), MEDLINE via OVID (1946 to November 2014) and EMBASE via OVID (1980 to November 2014). We also searched the U.S. National Institutes of Health Trials Register (https://clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (http://apps.who.int/trialsearch) for ongoing trials. We did not place any restrictions on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

Randomised controlled trials (RCTs), with an intervention and follow-up period of at least two years, comparing fluoridated milk with non-fluoridated milk.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial risk of bias and extracted data. We used standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included one unpublished RCT, randomising 180 children aged three years at study commencement. The setting was nursery schools in an area with high prevalence of dental caries and a low level of fluoride in drinking water. Data from 166 participants were available for analysis. The study carried a high risk of bias. After three years, there was a reduction of caries in permanent teeth (mean difference (MD) -0.13, 95% confidence interval (CI) -0.24 to -0.02) and in primary teeth (MD -1.14, 95% CI -1.86 to -0.42), as measured by the decayed, missing and filled teeth index (DMFT for permanent teeth and dmft for primary teeth). For primary teeth, this is a substantial reduction, equivalent to a prevented fraction of 31%. For permanent teeth, the disease level was very low in the study, resulting in a small absolute effect size. The included study did not report any other outcomes of interest for this review (adverse events, dental pain, antibiotic use or requirement for general anaesthesia due to dental procedures).

AUTHORS' CONCLUSIONS

There is low quality evidence to suggest fluoridated milk may be beneficial to schoolchildren, contributing to a substantial reduction in dental caries in primary teeth. Due to the low quality of the evidence, further research is likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. There was only one relatively small study, which had important methodological limitations on the data for the effectiveness in reducing caries. Furthermore, there was no information about the potential harms of the intervention. Additional RCTs of high quality are needed before we can draw definitive conclusions about the benefits of milk fluoridation.

Fluoridated milk for preventing dental caries

BACKGROUND

Dental caries remains a major public health problem in most industrialised countries, affecting 60% to 90% of schoolchildren and the vast majority of adults. Milk may provide a relatively cost-effective vehicle for fluoride delivery in the prevention of dental caries. This is an update of a Cochrane review first published in 2005.

OBJECTIVES

To assess the effects of milk fluoridation for preventing dental caries at a community level.

SEARCH METHODS

We searched the Cochrane Oral Health Group Trials Register (inception to November 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2014, Issue 10), MEDLINE via OVID (1946 to November 2014) and EMBASE via OVID (1980 to November 2014). We also searched the U.S. National Institutes of Health Trials Register (https://clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (http://apps.who.int/trialsearch) for ongoing trials. We did not place any restrictions on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

Randomised controlled trials (RCTs), with an intervention and follow-up period of at least two years, comparing fluoridated milk with non-fluoridated milk.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial risk of bias and extracted data. We used standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included one unpublished RCT, randomising 180 children aged three years at study commencement. The setting was nursery schools in an area with high prevalence of dental caries and a low level of fluoride in drinking water. Data from 166 participants were available for analysis. The study carried a high risk of bias. After three years, there was a reduction of caries in permanent teeth (mean difference (MD) -0.13, 95% confidence interval (CI) -0.24 to -0.02) and in primary teeth (MD -1.14, 95% CI -1.86 to -0.42), as measured by the decayed, missing and filled teeth index (DMFT for permanent teeth and dmft for primary teeth). For primary teeth, this is a substantial reduction, equivalent to a prevented fraction of 31%. For permanent teeth, the disease level was very low in the study, resulting in a small absolute effect size. The included study did not report any other outcomes of interest for this review (adverse events, dental pain, antibiotic use or requirement for general anaesthesia due to dental procedures).

AUTHORS' CONCLUSIONS

There is low quality evidence to suggest fluoridated milk may be beneficial to schoolchildren, contributing to a substantial reduction in dental caries in primary teeth. Due to the low quality of the evidence, further research is likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. There was only one relatively small study, which had important methodological limitations on the data for the effectiveness in reducing caries. Furthermore, there was no information about the potential harms of the intervention. Additional RCTs of high quality are needed before we can draw definitive conclusions about the benefits of milk fluoridation.

A systematic review on fluoridated food in caries prevention

OBJECTIVE

This paper aims to provide a systematic review of the caries-prevention effect of fluoridated food, excluding water. The main aim of this review was to evaluate the presence of scientific evidence relating to the effects of fluoride intake via food on the occurrence of carious lesions. The outcome was defined as a clinical outcome, so only papers evaluating a decrease in caries indices were included.

MATERIALS AND METHODS

Relevant databases (Medline®, Embase®, The Cochrane Library) were searched. The date range was set from 01.01.1966 to 03.31.2011. One hundred and thirty-nine reports were identified and assessed. Only three papers fulfilled the inclusion criteria and were discussed in detail.

RESULTS

No paper related to the use of fluoridated salt in caries prevention fulfilled the inclusion criteria. The use of milk as a vehicle for providing additional fluoride in a dental public health programme was evaluated in two papers. The consumption of fluoridated milk was an effective measure to prevent caries in the primary teeth. The use of fluoridated sugar demonstrated a reduction in caries increment in the permanent dentition in one paper.

CONCLUSIONS

Literature on the effectiveness of fluoridation in foods in caries prevention is scant and almost all the studies have been conducted in children. There is low evidence that the use of milk fluoridation is effective in reducing the caries increment.

Urinary fluoride excretion in 6- to 7-year-olds ingesting milk containing 0.5 or 0.9 mg fluoride

Effectiveness of 0.5 mg fluoride (F) milk ingestion in preventing caries has been termed only 'moderate'. In this 3-arm partial cross-over intervention, 32 children aged 6-7 years in a non-F area were recruited and urinary F excretion (UFE) measured before and after ingestion of 0.5 or 0.9 mg F milk. Maintaining customary dietary and oral hygiene habits, children underwent a 2-week 'wash-in' with non-F milk, providing a 24-hour urine sample on day 4 of non-F (baseline) and F milk ingestion containing either (i) 0.5 mg or (ii) 0.9 mg F (intervention). A comparative group of thirteen 6- to 7-year-olds living in fluoridated areas provided a 24-hour urine sample on day 4 of daily non-F milk ingestion, following a 2-week non-F milk wash-in. Valid urine samples were analysed for F and UFE estimated from corrected 24-hour urine volume and F concentration. For the 24 test children providing 2 valid urine samples, mean (95% CI) change in corrected 24-hour UFE was 0.130 (0.049, 0.211) and 0.153 (0.062, 0.245) mg/day for 0.5 mg (p < 0.007) and 0.9 mg F (p < 0.001) groups, respectively. Post-intervention, mean (SD) corrected 24-hour UFE was 0.437 (0.153) mg/day and 0.420 (0.188) mg/day for the 0.5 and 0.9 mg F groups, respectively, which were lower than the WHO provisional standards (0.48-0.60 mg F/day). F milk consumption significantly increased UFE; however, the F content of 0.5 and 0.9 mg F milk may be too low to achieve WHO provisional UFE standards concomitant with optimal F exposure in children aged ≥6 years.

Effects of fluoridated milk on artificial enamel carious lesions: a pH cycling study

OBJECTIVE

To investigate the relationship between concentration of fluoride in milk and its re-mineralizing efficacy, and to test whether increasing the volume of fluoridated milk has any effect on its re-mineralizing efficacy.

METHODS

Third molars were painted leaving a 1 mm window on the buccal and/or lingual surfaces. Artificial carious lesions were induced using a de-mineralizing solution. The teeth were then sectioned longitudinally. Specimens were randomly assigned to 15 groups according to different concentrations and volume; i.e., 2.5 ppm, 5 ppm, 7.5 ppm, 10 ppm, 15 ppm, 20 ppm, and 250 ppm of fluoride with 25 ml/section and 50 ml/section. De-ionized water and plain milk were used as controls. Sections were subjected to pH cycling for 20 days. Polarized light microscopy and micro-radiography were utilized to record the lesion characteristics before and after pH cycling.

RESULTS

Mean lesion depths decreased significantly in all the fluoride groups, and increased significantly in the control groups. There were no differences in percentage of lesion depth decrease when the volume was doubled for the same fluoride concentration. There were also no statistically significant differences between percentages of decrease in lesion depth when the concentration of fluoride in milk was increased.

CONCLUSION

Fluoridated milk demonstrated a remineralization efficacy on early enamel carious lesions. A 2.5 ppm fluoride milk concentration provided similar remineralization potential to that of higher fluoride concentration in milk.

Children's acceptance of milk with xylitol or sorbitol for dental caries prevention

Background

Xylitol, a polyol sugar, has been shown to reduce dental caries when mixed with food or chewing gum. This study examines the taste acceptability of xylitol in milk as a first step toward measuring the effectiveness of xylitol in milk for the reduction of dental caries in a public health program.

Methods

Three different types of milk (Ultra High Temperature (UHT), powder and evaporated) were tested for acceptability by 75 Peruvian children (25 per milk group, ages 4 to 7 years). Each group evaluated xylitol and sorbitol in one type of milk. In the first phase, each child was presented with a tray of four plastic cups containing 50 ml of milk with 0.021 g/ml xylitol, 0.042 g/ml xylitol, 0.042 g/ml sorbitol or no sugar. Each child was asked to taste the samples in a self-selected order. After tasting each sample, the child placed the milk cup in front of one of three cartoon faces (smile, frown or neutral) representing the child's response to the taste of each sample. In the second phase, the child was asked to rank order the milk samples within each category (smile, frown or neutral). Ranks within categories were then combined to obtain a rank ordering for all the test samples.

Results

The ranking from best to worst for the samples across categories (UHT, powder, evaporated) was xylitol (0.0.042 g/ml), sorbitol (0.042 g/ml), xylitol (0.021 g/ml) and milk alone (Friedman's ANOVA). Xylitol and sorbitol were preferred over milk alone, and xylitol (0.042 g/ml) was preferred to sorbitol (0.042 g/ml)(p < .05 sign test).

Conclusion

Milk sweetened with xylitol is well accepted by Peruvian children ages 4–7 years.

Fluoridated milk for preventing dental caries

BACKGROUND

Dental caries remains a major public health problem in most industrialised countries, affecting 60% to 90% of school children and the vast majority of adults. Milk provides a relatively cost-effective vehicle for fluoride in the prevention of dental caries.

OBJECTIVES

To determine the effectiveness of fluoridated milk, as a means of delivering fluoride on a community basis, for preventing dental caries.

SEARCH STRATEGY

We searched Cochrane Oral Health Group Trials Register (28 April 2005), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2005), MEDLINE (1966 to 17 May 2005), OLDMEDLINE (1950 to 1965), EMBASE (1980 to 2005 week 20), LILACS (1982 to 17 May 2005), BBO (1986 to 17 May 2005), SIGLE (1980 to 17 May2005), Digital Dissertations (1861 to 17 May 2005) and reference lists of relevant articles. Attempts were made to identify both unpublished and ongoing studies. There were no language restrictions.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials (RCTs), with an intervention or follow-up period of at least 3 years, comparing fluoridated milk with non-fluoridated milk. Primary outcome was change in caries experience, as measured by changes in decayed, missing and filled figures on tooth (dmft/DMFT) and surface (dmfs/DMFS).

DATA COLLECTION AND ANALYSIS

Inclusion decisions, data extraction and quality assessment were carried out independently and in duplicate. Study authors were contacted for additional information where necessary.

MAIN RESULTS

Two RCTs involving 353 children were included. For permanent teeth, after 3 years there was a significant reduction in the DMFT (78.4%, P < 0.05) between the test and control groups in one trial, but not in the other. The latter study only showed a significant reduction in the DMFT until the fourth (35.5%, P < 0.02) and fifth (31.2%,P < 0.05) years. For primary teeth, again there was a significant reduction in the dmft (31.3%, P< 0.05) between the test and control groups after 3 years in one study, but not in the other. The results could not be pooled because of the difference in concentration of fluoride in the milk.

AUTHORS' CONCLUSIONS

There are insufficient studies with good quality evidence examining the effects of fluoridated milk in preventing dental caries. However, the included studies suggested that fluoridated milk was beneficial to school children, especially their permanent dentition. The data need to be supplemented by further RCTs to provide the highest level of evidence for practice.

Caries Prevalence in a Rural Chilean Community after Cessation of a Powdered Milk Fluoridation Program

OBJECTIVE

The milk fluoridation scheme established in Codegua, Chile, between 1994 and 1999 demonstrated the effectiveness of powdered milk as a community-based vehicle for fluoride to prevent dental caries. The present study aimed to compare caries prevalence in both the Codeguan control and test communities, three years after ending fluoride distribution through the powdered milk fluoridation scheme, to assess whether the benefits of such milk fluoridation were still present in the test community.

METHODS

Children 3-6 years old living in Codegua (test community) and La Punta (control community) were examined for dental caries at their educational facilities by three trained and calibrated examiners using natural light, dental mirrors, and sickle probes. Differences in caries prevalence (dmfs) by year of the study were tested for statistically significant differences using the Mann-Whitney U test.

RESULTS

Findings from Codegua (1999-2002) indicate that the dental caries experience increased in all age groups following the termination of powdered milk fluoridation. These differences reached levels of statistical significance in the 3-, 4-, and 5- year old group (P < .03). Comparing results from Codegua and La Punta (2002), no statistically significant differences were found.

CONCLUSIONS

Termination of the powdered milk fluoridation scheme resulted in a deterioration of the dental health of children. After three years, dental caries prevalence was higher than that reached at the end of the scheme and equivalent to that of the control community without fluoride exposure. These results emphasize the need to establish and maintain an alternative mechanism of community-based fluoridation of proven effectiveness for the prevention of dental caries in communities where water fluoridation is not available.

Composition of the salivary microflora during habitual consumption of fluoridated milk

The aim was to evaluate the effect of habitual consumption of fluoridated milk on the composition of the salivary microflora. The study group comprised 20 healthy schoolchildren and young adults with a mean age of 13.6 years and the investigation had a randomized double-blind crossover design with a washout period of 1 month. After professional tooth-cleaning at baseline, the subjects were supplied with either fluoridated (250 mL, 5 ppm F) or non-fluoridated milk for one daily intake during a period of 4 weeks. Salivary samples were collected immediately before tooth-cleaning and after 1, 2, and 4 weeks, respectively. The samples were immediately cultivated for total viable counts, oral streptococci, mutans streptococci, lactobacilli, and actinomyces spp. Bacterial counts were logarithmically transformed before statistical evaluation using ANOVA. No significant alterations of the salivary microflora were found during any of the milk regimens compared with baseline. There was a slight reduction in the proportion of mutans streptococci after 2 and 4 weeks during consumption with fluoridated milk but the difference failed to reach statistical significance. In conclusion, this study was unable to disclose any significant alteration of the composition of the salivary microflora following daily intake of fluoridated milk.

Oral health among Vietnamese using a community health centre in Richmond, Victoria

BACKGROUND

The purpose of this study was to assess the prevalence of specific oral diseases in a Vietnamese background population living in Melbourne, Australia, and to compare these findings to existing oral health data.

METHODS

One hundred and fifty-eight subjects of Vietnamese background, 18 and older, participated in the study.

RESULTS

Subjects were clinically examined, in a cross-sectional study, using standard World Health Organization criteria. The mean decayed, missing and filled surfaces scores were 27.8 (26.1). With the exception of one person, all subjects displayed clinical signs of gingivitis and 39 per cent had shallow pockets. Complex periodontal therapy was required by about 5 per cent of the sample. Comparing these findings to existing data on oral health in Melbourne, subjects in the study had lower DMFS scores, a higher number of untreated decayed surfaces and higher prevalence of gingivitis but less need for advanced periodontal treatment.

CONCLUSIONS

These findings, in terms of dental caries and periodontal disease, represent a more encouraging oral health situation than that previously described in this immigrant population. Inequalities within the present sample were not reflected in the overall caries experience but were reflected in the proportion of unmet restorative needs. Further research is needed to get a clearer picture of the factors that shape the oral health of migrant Vietnamese populations and expansion of this research into other migrant groups is also necessary.