Professional fluoride varnish treatment for caries control: a systematic review of clinical trials

Characteristics of phase 4 clinical trials on Dental Caries registered at Clinicaltrials.gov

BACKGROUND

Dental caries, a widespread chronic oral disease, is caused by multiple factors including microorganisms, genetic predisposition. Despite being preventable, it poses a significant global burden. This study reviews all phase 4 clinical trials on dental caries registered at ClinicalTrials.gov to provide a comprehensive overview of their characteristics.

METHODS

A search was conducted on the ClinicalTrials.gov database using keywords. The registration data for all relevant phase 4 studies concerning 'Dental Caries' were retrieved. This search was conducted on the 23rd of January, 2024.

RESULTS

The analysis included 58 phase 4 clinical trials, with most studies (67.2%) reporting complete data. The majority (63.8%) had fewer than 100 participants, and the predominant sponsors were medical institutions (77.6%). Geographically, the highest percentage of studies were conducted in South America (24.1%), with the lowest in North America (10.3%). Interventional trials primarily focused on treatment (51.7%) and prevention (41.4%), with a significant portion being randomized (93.1%). Blinding varied, with single and double blinding each used in 25.9% of studies. Drug interventions were the most common (60.6%), followed by other categories such as dietary supplements and procedures. Among drug interventions, agents containing fluoride were the largest category, accounting for 52.6% of the trials. Fluoride varnishes and silver diamine fluoride were the most frequently evaluated. Sedatives and pain relievers constituted 15.7% of the trials, with midazolam and ketamine being predominant. Other drugs accounted for 23.2% of the trials, featuring diverse substances such as inactivated poliovirus vaccine and xylitol. Dental materials and operative treatments made up 29.5% of the trials, with resin and fissure sealants being the most commonly evaluated.

CONCLUSION

This analysis of phase 4 clinical trials highlighted fluoride as the most studied intervention for dental caries prevention. The analysis also revealed a need for further research on non-fluoride interventions and emphasized the importance of using evidence-based practices in dental care for improved oral health outcomes.

CLINICAL TRIAL NUMBER

Not applicable.

An Alternative Technique for Topical Application of Acidulated Phosphate Fluoride (APF) Gel: A Two-Years Double-Blind Randomization Clinical Trial (RCT)

Background and Objectives: Dental caries is still a dramatic public health problem. The effectiveness of an alternative technique using acidulated phosphate fluoride (APF) gel pH 3.5 was evaluated and compared with conventional treatments in reducing dental caries incidence. Materials and Methods: A double-blind randomized controlled trial was conducted, involving 180 children aged 4-11 years. Three groups were formed: NaF varnish (NaFV), APF in tray (APFt), and APF in toothbrush (APFtbru). Clinical examinations were performed using standardized criteria and the ICDAS Index was assessed. The Caries Treatment Needs Index (CTNI) was calculated. Dental examinations were conducted at baseline, 12 months, and 24 months. Results: At baseline, 16,719 dental surfaces were included, with 15,434 surfaces being sound. After 24 months, the Kaplan-Meier analysis showed significant differences between the APFtbru group and the other two groups (p = 0.03). Cox regression analysis revealed that the surfaces treated with NaF varnish had the lowest survival rates (HR = 0.51 95%CI = 0.33/0.81). Occlusal surfaces had the lowest cumulative survival, while other tooth surfaces showed similar performance. Conclusions: The alternative technique of APF gel application with a toothbrush resulted in maintaining dental health over 24 months. This technique can be cost-effective and may offer advantages over traditional fluoride varnish application.

Caries-preventive effectiveness of two different fluoride varnishes: A randomised clinical trial in patients with multi-bracketed fixed orthodontic appliances

BACKGROUND

Patients with multi-bracketed fixed orthodontic appliances are at a higher risk of developing enamel demineralisation.

AIM

To compare the efficacy of the quarterly application of two varnishes in preventing white spot lesions (WSLs) during multi-bracketed fixed orthodontic treatment.

DESIGN

Ninety-nine patients were randomly allocated into three intervention groups: Group A-standard oral hygiene instructions (OHI); Group B-5% sodium fluoride (NaF) varnish with standard OHI; and Group C-NaF plus tricalcium phosphate varnish with standard OHI. The outcome was assessed at 6-monthly intervals using a quantitative laser fluorescence device, clinical evaluation and photographic evaluation on six maxillary anterior teeth. A logistic regression model using generalised estimating equations with the intervention group, time and their interaction was used to compare the occurrence of WSLs, whereas the independent-samples Kruskal-Wallis test was used to compare the means of fluorescent values among different groups at p = .05.

RESULTS

Generalised estimating equations (with intervention and time as predictors) showed that only the effect of time was found to be significant (p < .001), whereas there was no significant difference among the three intervention groups (p = .305) using clinical assessment or photographic assessment (p = .599). At the 18-month follow-up, sodium fluoride (NaF) varnish with standard OHI was shown to reduce the odds of WSLs by 55% (p = .200), and NaF plus tricalcium phosphate varnish with standard OHI by 42% (p = .327).

CONCLUSION

The study failed to demonstrate that the quarterly application of both the study varnishes with OHI provided additional benefits compared with standard OHI alone in preventing WSLs, taking the effect of time of follow-up into consideration. There were higher odds of developing WSLs with an increased duration of orthodontic treatment.

Effectiveness of Silver Diamine Fluoride and Sodium Fluoride Varnish in Preventing New Carious Lesion in Preschoolers: A Randomized Clinical Trial

Introduction

Dental caries is a site-specific, multifactorial chronic disease affected globally. The prevalence of dental caries is strongly associated with social and economic disadvantage, and also the susceptibility of children to dental caries. Dental caries prevention can be achieved with topical fluoride agents. Topical fluoride promotes the remineralization of early carious lesions and reduces the demineralization of healthy enamel.

Aim

The aim of this randomized clinical trial was to compare the effectiveness of silver diamine fluoride (SDF) and sodium fluoride varnish (FV) in preventing new carious lesions in preschoolers.

Materials and methods

This randomized clinical trial was conducted on 285 children aged 3-6 years. Children were randomly allocated into three groups namely, group I-deionized distilled water (DIW), group II-sodium FV, and group III-SDF. The biannual application was performed at an interval of 6 months. New carious lesions were recorded using defs and International Caries Detection and Assessment System (ICDAS II) under LED magnifying loupes. Descriptive and inferential statistics were applied and tabulated using Statistical Package for the Social Sciences (SPSS) 23.0 software.

Result

There was a significant difference seen in the mean values of group III (SDF) when compared with group II (FV) and also between group III (SDF) and group I (DIW) when defs index was used. The mean score of ICDAS II after 12 months in group I (DIW) was -1.171, group II (FV) was -0.690, and group III (SDF) was -0.374.

Conclusion

silver diamine fluoride (SDF) was found to be most effective in preventing dental caries and also it appears to be the most cost-saving fluoride therapy.

How to cite this article

Jain A, Deshpande AN, Shah YS, et al. Effectiveness of Silver Diamine Fluoride and Sodium Fluoride Varnish in Preventing New Carious Lesion in Preschoolers: A Randomized Clinical Trial. Int J Clin Pediatr Dent 2023;16(1):1-8.

Risk factors for and prevention of caries and dental erosion in children and adolescents with asthma

There are many studies and reviews of the relationship between the asthma disease in young individuals on the one hand and caries and dental erosion on the other. The causes of caries and dental erosion might be related to the asthmatic drugs, low pH and the sweeteners that the inhaled drug contains and perhaps even the lifestyle of children and adolescents with asthma. The main focus of this review is therefore to describe various preventive strategies, based on long experience of preventive dental care in Sweden. Two fact boxes are presented, one on fluoride toothpaste as a population-based intervention for different ages and one on diet counselling in children and adolescents with asthma. The most important thing is to introduce fluoride toothpaste early in the child's life and that the parents brush the child's teeth twice a day, in the morning after breakfast and at night before bedtime, up to the age of 10. Moreover, a high-risk approach with an additional fluoride supply at home is presented, together with the application of fluoride varnish at the clinic. Regarding diet counselling, it is important to make sure that the child has regular meals during the day, maximum five to six times a day, to allow the teeth to rest between meals and restrict sweets and soft drinks to once a week. It is important to identify children and adolescents with asthma as early as possible and to refer them to a dental team for preventive treatment.

Long-Term Cost-Effectiveness through the Dental-Health FRAMM Guideline for Caries Prevention

A guideline called FRAMM, which is an acronym in Swedish for the most important parts of this guideline, namely “fluoride”, “advice”, “arena”, “motivation” and “diet”, was implemented in 2008 in the Västra Götaland Region in Sweden. This guideline included fluoride varnish applications performed at school twice a year at six-monthly intervals for all 12- to 15-year-olds, together with lessons on oral health. The aim of this analysis was to estimate the long-term cost-effectiveness, using prognostic calculations, of the FRAMM Guideline for 12- to 15-year-olds, compared with routine care, until the participants were 23 years old. A cost-effectiveness analysis was performed from a health care perspective, based on four years of verified data and seven years of prognosis. Data from FRAMM were combined with cost data from price lists in Sweden. The cost-effectiveness was analyzed by relating the difference in costs to the difference in the number of approximal surfaces with fillings and/or dentin lesions (DFSa). The analysis shows that FRAMM was considered dominant compared to the controls in all alternative scenarios, hence costs were prognosed to be lowered and outcomes were prognosed to be improved. A dental health program like the FRAMM Guideline with fluoride varnish during the caries risk period from 12 to 15 years is predicted to be cost-effective in the longer perspective. To further study the actual long-term caries increment after a preventive dental health program would be of great interest to verify these results.

Review of Professionally Applied Fluorides for Preventing Dental Caries in Children and Adolescents

This review aims to evaluate the effectiveness of professional topical fluoride application on the prevention of dental caries in primary and permanent dentition. A web search was conducted for English papers published from 2000 to 2020, using various digital resources (Pubmed, Google Scholar, Cochrane Library, and ResearchGate). The keywords were “professionally applied fluoride”, “fluoride gel”, “fluoride varnish”, “fluoride foam”, “fluoride mouthrinses”, and “non-cavitated caries lesions”. Inclusion criteria: (a) participants: children and adolescents, treated in a dental care setting; (b) intervention: professionally applied fluorides (gel, varnish, foam, mouthrinse); (c) comparator: no professional treatment or other preventive treatments; (d) outcomes: clinical effectiveness (e.g., caries reduction, tooth remineralization); (e) study design: randomized controlled trials, systematic reviews, meta-analyses; (f) publication period: 1 January 2000–31 December 2021. Clinical studies about home-use fluoride products, discussion papers, in-vitro studies, case reports, non-English articles, and studies with unclear methodology were excluded. Topical fluoride applications are indicated for patients with active smooth surface caries and for patients in high caries risk groups. Both APF gel and fluoride varnish are effective and can be recommended for caries prevention in primary and permanent teeth. For children under the age of 6, only 2.26% fluoride varnish is recommended.

Pit and Fissure Sealant versus Fluoride Varnish for the Prevention of Dental Caries in School Children: A Systematic Review and Meta-Analysis

Children's dental health has become the main concern, due to the increase in caries prevalence amongst children. Pit and fissure sealant (PFS) and fluoride varnish (FV) are effective measures for preventing dental caries. However, the clinical efficacy of these interventions when compared to one another is uncertain. The aim of the present systematic review with meta-analysis was to compare pit and fissure sealants with fluoride varnish for caries prevention of first permanent molars among schoolchildren. This is a meta-Analysis, which involves randomized control trials that compare the effectiveness of PFS with FV within 24 months of follow-up. Five databases were searched from 1990 to 2019 to identify studies published in Arabic or English language. The risk ratio (RR) and 95% confidence intervals (CIs) were calculated using a random-effects model. A total number of 4 studies were included with overall of 1249 children in both groups. Three included trial reported caries increment of first permanent molars (FPM) with 24 months of follow-up, there was no statistical significance (RR: 0.65; 95% CI 0.31 to 1.35; P = 0.26 I2 = 89%). As regards DMFS increment, the analysis showed no statistical differences between FV and PFS in terms of lowering DMFS increment (MD: 0.09; 95% CI: -0.03 to 0.21). Findings of this meta-analysis proved there is no significant difference between PFS and FV in caries prevention efficacy of FPMs at 2 years' follow-up, emphasizing the use of FV since it is more affordable and easier to apply.

Topical fluoride to prevent early childhood caries: Systematic review with network meta-analysis

OBJECTIVES

To summarize the evidence on prevention of early childhood caries (ECC) by professionally or self-applied topical fluorides using network meta-analysis.

DATA

Randomized-controlled trials with minimum 1-year follow-up assessing caries-preventive effect among children younger than six years.

SOURCES

Eight electronic databases and grey literature.

STUDY SELECTION

After screening and data extraction, risk of bias assessment using Cochrane risk of bias tool 2.0 was done. Twenty-four trials were included, among which 17 were assessed as "high risk" and remaining as "low risk". Fifteen studies evaluated professionally-applied, and the other nine used self-applied topical fluorides. Ten studies on professionally-applied fluorides reporting the net caries increment (dmfs increment) at 2-years follow-up were included in Network meta-analysis (NMA). NMA and ranking the interventions were conducted using a frequentist random-effects approach and surface under the cumulative ranking command, followed by assessing the certainty of evidence using an extension of GRADE approach with CINeMA framework. Among the eight included interventions of professionally-applied fluorides, only two, i.e., 3-monthly 0.9% difluorosilane (DFS) and 6-monthly 5% sodium fluoride varnish were effective in preventing ECC compared to control with 3-monthly DFS application ranking higher than 6-monthly sodium fluoride varnish application.

CONCLUSION

Among all the professionally-applied topical fluoride interventions reviewed, very low to moderate evidence was found with 0.9% DFS application at 3-monthly intervals, which was ranked highest in prevention of ECC. Among the included studies on self-applied topical fluorides, the evidence was inconclusive due to heterogeneity among studies.

CLINICAL SIGNIFICANCE

The 0.9% DFS varnish applied every 3 months is most effective for preventing early childhood caries. The review recommends that good quality studies be conducted in future, comparing two or more interventions for both self- as well as professionally-applied topical fluoride agents with adequate follow-up.

Fluoride Varnish Application in Preschoolers Have a Modest Effectiveness in Reducing the Incidence of Dentinal Caries

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION

Fluoride Varnish and Dental Caries in Preschoolers: A Systematic Review and Meta-Analysis. de Sousa FSO, Dos Santos APP, Nadanovsky P, Hujoel P, Cunha-Cruz J, de Oliveira BH. Caries Res. 2019;53(5):502-513.

SOURCE OF FUNDING

Government.

TYPE OF STUDY/DESIGN

Systematic review with meta-analysis of data.

An in-vitro evaluation of fluoride content and enamel remineralization potential of two toothpastes containing different bioactive glasses

BACKGROUND

Many novel biomaterials have been incorporated in toothpastes to promote remineralization of tooth structure.

OBJECTIVES

This study was carried out to compare the discrepancies between declared and actual total fluoride (TF) or total soluble fluoride (TSF) concentration of two modern toothpastes containing bioactive glasses; these were also assessed for their remineralization potential.

MATERIALS AND METHODS

The TF and TSF concentration were assessed using a fluoride ion selective electrode. Enamel remineralization was evaluated through micro-hardness analysis. Eighteen enamel blocks were divided into three groups: 1 (n = 6; control), 2 (n = 6; Novamin® toothpaste), and 3 (n = 6; BiominF® toothpaste). The specimens were demineralized by 6 wt% citric acid (pH = 2.2). Subsequently, the specimens in group 1 were kept in artificial saliva (AS), while the specimens in groups 2 and 3 were stored in AS + Novamin® and AS + Biomin®, respectively.

RESULTS

Both Novamin® or BiominF® showed less TF concentration than their label claims. BiominF® had more TF and TSF compared to Novamin® (p < 0.05). The BiominF® toothpaste presented higher micro-hardness values on remineralization.

CONCLUSION

BiominF® toothpaste demonstrated more fluoride content and greater potential to promote remineralization of demineralized human enamel compared to Novamin®.

Comparative Evaluation of the Remineralizing Efficacy of Fluoride Varnish and its Combination Varnishes on White Spot Lesions in Children with ECC: A Randomized Clinical Trial

Aim

The aim of the study was to assess the remineralizing efficacy of fluoride and its combination varnishes on white spot lesion (WSL) in children with early childhood caries (ECC).

Materials and methods

Sixty children with active WSL on primary maxillary anterior teeth were randomly selected. At baseline, the WSL activity was evaluated using ICDAS II [lesion activity assessment (LAA)] and its dimensions through photographic method. They were allocated to group I (GI) (5% NaF), group II (GII) [5% NaF with amorphous calcium phosphate (ACP)], and group III (GIII) [5% NaF with casein phosphopeptides - amorphous calcium phosphate (CPP -ACP)]. First, oral hygiene instructions and diet counseling were given followed by application of fluoride varnishes in their respective groups. The same parameters were recorded at follow-up of 2, 4, 12, and 24 weeks intervals. Data were collected and subjected to statistical analysis using Friedman Chi-square and Mann-Whitney tests.

Results

Overall, the active WSL changed to inactive over a period of 24 weeks in GI was 90%, GII was 95%, and 100% in GIII. There was a significant reduction in dimension of WSL in GI from 4.119 to 2.525 (p = 0.0001). Likewise, there was a significant reduction in dimension of WSL in GII and GIII from 4.586 to 3.258 and 4.696 to 1.2155, respectively (p = 0.0001, p = 0.0001). Comparatively, group III (MI varnish) showed statistically significant reduction in the dimension of WSL from baseline to 24 weeks (p = 0.002). But the results were statistically insignificant with change of active lesions to its inactivity (p = 0.349).

Conclusion

Fluoride varnish with CPP-ACP was found to be an effective preventive strategy in reversing WSL in children with ECC.

Clinical relevance

These combination varnishes could prove to be a promising preventive measure for pediatric dentists in reversing white spot lesions of ECC.

Clinical trial registry

NCT03360266.

How to cite this article

Radha S, Kayalvizhi G, Adimoulame S, et al. Comparative Evaluation of the Remineralizing Efficacy of Fluoride Varnish and its Combination Varnishes on White Spot Lesions in Children with ECC: A Randomized Clinical Trial. Int J Clin Pediatr Dent 2020;13(4):311-317.

Pit and fissure sealants versus fluoride varnishes for preventing dental decay in the permanent teeth of children and adolescents

BACKGROUND

Most of the detected increment in dental caries among children above the age of six years and adolescents is confined to occlusal surfaces of posterior permanent molars. Dental sealants and fluoride varnishes are much used to prevent caries. As the effectiveness of both interventions in controlling caries as compared with no intervention has been demonstrated previously, this review aimed to evaluate their relative effectiveness. It updates a review published originally in 2006 and updated in 2010 and in 2016.

OBJECTIVES

Our primary objective 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. Our secondary objectives were to evaluate whether effectiveness is influenced by sealant material type and length of follow-up, document and report on data concerning adverse events associated with sealants and fluoride varnishes, and report the cost effectiveness of dental sealants versus fluoride varnish in caries prevention.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 19 March 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2020, Issue 2), MEDLINE Ovid (1946 to 19 March 2020) and Embase Ovid (1980 to 19 March 2020). We searched the US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. There were no restrictions on the language or date of publication.

SELECTION CRITERIA

We included randomised controlled trials with at least 12 months of follow-up comparing fissure sealants, or fissure sealants plus fluoride varnishes, versus fluoride varnishes, for preventing caries in the occlusal surfaces of permanent posterior teeth (i.e. premolar or molar teeth), in participants younger than 20 years of age at the start of the study.

DATA COLLECTION AND ANALYSIS

At least two review authors independently screened search results, extracted data from included studies and assessed their risk of bias. We attempted to contact study authors to obtain missing or unclear information. We grouped and analysed studies on the basis of sealant material type: resin-based sealant or glass ionomer-based sealant (glass ionomer and resin-modified glass ionomer sealant), and different follow-up periods. We calculated the odds ratio (OR) for risk of caries on occlusal surfaces of permanent molar teeth. For trials with a split-mouth design, we used the Becker-Balagtas OR. One cluster-randomised trial provided precise estimates in terms of risk ratio (RR), which we used. For continuous outcomes and data, we used means and standard deviations to obtain mean differences (MD). For meta-analysis, we used the random-effects model when we combined data from four or more studies. We presented all measures with 95% confidence intervals (CIs). We assessed the certainty of the evidence using GRADE criteria.

MAIN RESULTS

We included 11 trials with 3374 participants aged five to 10 years when trials started. Three trials are new since the 2016 update. Two trials did not contribute data to our analysis. Sealant versus fluoride varnish Resin-based fissure sealants versus fluoride varnishes Seven trials evaluated this comparison (five contributing data). We are uncertain if resin-based sealants may be better than fluoride varnish, or vice versa, for preventing caries in first permanent molars at two to three years' follow-up (OR 0.67, 95% CI 0.37 to 1.19; I² = 84%; 4 studies, 1683 children evaluated). One study measuring decayed, missing and filled permanent surfaces (DMFS) and decayed, missing and filled permanent teeth (DMFT) increment at two years suggested a small benefit for fissure sealant (DMFS MD -0.09, 95% CI -0.15 to -0.03; DMFT MD -0.08, 95% CI -0.14 to -0.02; 542 participants), though this may not be clinically significant. One small study, at high risk of bias, reported a benefit for sealant after four years in preventing caries (RR 0.42, 95% CI 0.21 to 0.84; 75 children) and at nine years (RR 0.48, 95% CI 0.29 to 0.79; 75 children). We assessed each of these results as having very low certainty. Glass ionomer-based sealants versus fluoride varnishes Three trials evaluated this comparison: one trial with chemically cured glass ionomer and two with resin-modified glass ionomer. Studies were clinically diverse, so we did not conduct a meta-analysis. 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. We assessed this evidence as very low certainty. Sealant plus fluoride varnish versus fluoride varnish alone One split-mouth trial analysing 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), which represented a clinically meaningful effect of a 77% reduction in caries after two years; however, we assessed this evidence as very low certainty. Adverse events Five trials (1801 participants) (four using resin-based sealant material and one using resin-modified glass ionomer) reported that no adverse events resulted from use of sealants or fluoride varnishes over one to nine years. The other studies did not mention adverse events.

AUTHORS' CONCLUSIONS

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.

Effects of the professional oral care management program on patients with head and neck cancer after radiotherapy: A 12-month follow-up

Background/purpose

Because oral health of patients with head & neck cancer is prone to disease after radiotherapy, effective and long-lasting oral care program is necessary. We aimed to evaluate the effects of the oral care management program, which lasted up to 12 months after radiotherapy for patients with head and neck cancer.

Materials and methods

Sixty-eight patients who visited a dental clinic prior to the initiation of radiotherapy were recruited and categorized into either a “healthy” or a “vulnerable” group. The vulnerable group was made of patients with dental caries or periodontal attachment loss. Professional oral hygiene care, including tooth brushing instructions, professional mechanical tooth cleaning, and fluoride varnish application, was conducted once every week for a month during radiotherapy and once every 3 months after radiotherapy. Oral health, including dental caries, plaques, gingival index, and periodontal attachment loss, was examined at baseline, 6 months, and 12 months after radiotherapy.

Results

; Twenty-nine and 16 patients were followed up at 6 and 12 months after radiotherapy, respectively. Oral health indices, such as the number of decayed teeth, amount of plaque, and gingival index, did not significantly change in either group. However, the periodontal pocket depth significantly decreased in both groups at 6 months after baseline, and this decrease continued in the vulnerable group up to 12 months after baseline.

Conclusion

Periodic dental visits and professional oral hygiene care during and after radiotherapy were effective in maintaining oral health for over 12 months after radiotherapy in patients with head and neck cancer.

Prevalence and incidence of dental caries associated with the effect of tooth brushing and fluoride varnishing in schoolchildren at Galapagos Islands, Ecuador: Protocol of the EESO-Gal study

Introduction

Dental caries is the most prevalent oral disease in Ecuador. In our country, there are no studies that have included the population of the Galapagos Islands. Fluoride application to incipient lesions of dental caries has shown to be effective in avoiding the use of invasive restorative procedures.

Objectives

The objective of the EESO-Gal study is to determine the prevalence and incidence of dental caries and to evaluate the effect of supervised dental brushing, accompanied by periodic applications of fluoride varnish on incipient precarious lesions of schoolchildren in the Galapagos Islands. This article presents the protocol of the EESO-Gal study.

Methods

A cohort is planned with Galapagos Islands schoolchildren to determine the prevalence and incidence of dental caries, with assessments every six months, during twenty-four months.

Results

We expect to determine the prevalence and incidence of caries every six months, for twenty-four months, in schoolchildren between three and ten years of age, and obtain data to show the state of the caries conditions in Galapagos schoolchildren, with the inclusion of daily brushing at school, supervised by the teacher, and with the application of fluoride varnish every six months.

Conclusions

The prevalence of dental caries and incidence after the program will demonstrate the importance of implementing oral health prevention and promotion actions to create hygiene and health habits from an early age.

Fluoride Varnish and Dental Caries in Preschoolers: A Systematic Review and Meta-Analysis

The aim of this study was to assess the effectiveness of fluoride varnish (FV) in reducing dentine caries at the patient, tooth, and surface levels as well as caries-related hospitalizations in preschoolers. We performed a systematic review of clinical trials of FV, alone or associated with an oral health program, compared with placebo, usual care, or no intervention. Bibliographical search included electronic searches of seven databases, registers of ongoing trials, and meeting abstracts, as well as hand searching. We performed random-effects meta-analyses and calculated confidence and prediction intervals. The search yielded 2,441 records; 20 trials were included in the review and 17 in at least one meta-analysis. Only one study had low risk of bias in all domains. We found no study reporting on caries-related hospitalizations. At the individual level, the pooled relative risk was 0.88 (95% confidence interval [CI] 0.81, 0.95); this means that in a population of preschool children with 50% caries incidence, we need to apply fluoride varnish in 17 children to avoid new caries in one child. At the tooth level, the pooled weighted mean difference was –0.30 (95% CI –0.69, 0.09) and at the surface level –0.77 (95% CI –1.23, –0.31). Considering the prediction intervals, none of the pooled estimates were statistically significant. We conclude that FV showed a modest and uncertain anticaries effect in preschoolers. Cost-effectiveness analyses are needed to assess whether FV should be adopted or abandoned by dental services.

Fluoride varnish for the prevention of white spot lesions during orthodontic treatment with fixed appliances: a randomized controlled trial

Background

Self-applied and professional fluorides are key elements to limit caries-related side-effects during orthodontic treatment with fixed appliances.

Objective

To evaluate the effectiveness of a new fluoride varnish formula containing 1.5% ammonium fluoride in preventing white spot lesions (WSLs) in adolescents undergoing multi-bracket orthodontic treatment.

Subjects and methods

The study employed a randomized controlled triple-blinded design with two parallel arms. One hundred eighty-two healthy adolescents (12–18 years) referred to three orthodontic specialist clinics were eligible and consecutively enrolled. Informed consent was obtained from 166 patients and they were randomly allocated to a test or a placebo group (with aid of a computer program, generating sequence numbers in blocks of 15). In the test group, fluoride varnish was applied in a thin layer around the bracket base every sixth week during the orthodontic treatment, while patients in the placebo group received a varnish without fluoride. The intervention started at onset of the fixed appliances and continued until debonding. The endpoint was prevalence and severity of WSLs on the labial surfaces of the maxillary incisors, canines, and premolars as scored from high-resolution pre- and post-treatment digital photos with aid of a four-level score.

Results

One hundred forty-eight patients completed the trial, 75 in the test group and 73 in the placebo group (dropout rate 10.8%). The total prevalence of WSL’s on subject level after debonding was 41.8% in the test group and 43.8% in the placebo group. The number of patients exhibiting more severe lesions (score 3 + 4) was higher in the placebo group (P &lt; 0.05); the absolute risk reduction was 14% and the number needed to treat was 7.1.

Limitations

The multicentre design with somewhat diverging routines at the different clinics may have increased risk for performance bias. No health-economic evaluation was carried out.

Conclusions

Regular applications of an ammonium fluoride varnish reduced the prevalence of advanced WSL during treatment with fixed orthodontic appliances.

Clinical trial registration

ClinicalTrials.gov (NCT03725020).

Protocol

The protocol was not published before trial commencement.

Enamel protection after stripping procedures: An in vivo study

INTRODUCTION

Interproximal enamel reduction (IPR) is a clinical procedure that has been in use since the advent of non-extraction orthodontic techniques. However, such a procedure affects the surface condition of the enamel and may predispose patients to cavities and hypersensitivity. The use of a remineralizing agent is recommended to prevent these side effects. The objective of our study was to evaluate the evolution of stripped proximal dental surfaces after exposure to the oral environment for 4 months with and without fluoride protection.

MATERIALS AND METHODS

Our sample consisted of 14 premolars (PM) from 6 patients of the Dentofacial Orthopaedics Department of the Consultation and Dental Treatment Centre of Rabat (CDTC) who required orthodontic treatment with PM extraction and had given their informed consent. The teeth were divided into 5 groups: group 1: intact enamel; group 2: intact enamel+fluoride varnish+4-month oral exposure; group 3: IPR (manual and mechanized)+extraction; group 4: IPR (manual and mechanized) without varnish+4-month oral exposure; group 5: IPR (manual and mechanized)+fluoride varnish+4-month oral exposure. Proximal surfaces were subjected to qualitative analysis by scanning electron microscopy and quantitative analysis by Dispersive Energy Spectroscopy (DES) to quantify the percentage of mineral elements.

RESULTS

Exposure of stripped dental surfaces to the oral environment for 4 months with or without fluoride protection showed the persistence of surface irregularities caused by stripping. We noted an improvement in the percentage of mineral elements for both groups with and without fluoride protection. However, the percentages of calcium (Ca) and phosphorus (P) were close to that of intact enamel in the fluoride varnish group.

CONCLUSION

Protecting stripped surfaces with fluoride varnish could help preserve the integrity of the enamel surface by restoring some of the mineral elements lost during stripping.

Sodium fluoride and silver diamine fluoride-coated tooth surfaces inhibit bacterial acid production at the bacteria/tooth interface

OBJECTIVES

This study aimed to evaluate whether coating tooth surfaces with sodium fluoride (NaF) or silver diamine fluoride (SDF) inhibits bacteria-induced pH reductions at the bacteria/tooth interface.

METHODS

Specimens of coronal enamel (CE) or root dentin (RD) were prepared. The surfaces of the specimens were treated with 2% NaF or 38% SDF solution. Some specimens were aged for 1 week after being treated. A tooth specimen was fixed to the bottom of the well of the experimental apparatus. A miniature pH electrode was placed on the specimen and the well was filled with Streptococcus mutans (SM) cells. The pH was monitored after the addition of 0.5% glucose. SM cells were recovered from the wells, and the amounts of lactate, calcium, fluoride, and silver were measured.

RESULTS

The fluoride-treated tooth specimens exhibited significantly higher pH values than the untreated controls, irrespective of the tooth substrate at 120 min (CE: NaF 4.62 ± 0.06 vs 4.34 ± 0.10 and SDF 5.23 ± 0.29 vs 4.44 ± 0.16, RD: NaF 5.10 ± 0.11 vs 4.54 ± 0.33 and SDF 6.65 ± 0.47 vs 4.64 ± 0.39). The SDF-coated RD specimens released the greatest amounts of fluoride (103.3 ± 48.1 nmol/well) and silver (70.4 ± 36.9 nmol/well), while they exhibited significantly lower lactate production and decalcification (calcium release) than the control samples (lactate: 4.0 ± 0.7 vs 7.4 ± 0.3 mmol/l, calcium: 2.2 ± 0.4 vs 3.7 ± 0.5 μg/ml). This antimicrobial effect was weakened by 1 week's aging, while the acid resistance of the fluoride-treated surfaces seemed to increase with aging.

CONCLUSIONS

Fluoride-treated tooth surfaces inhibit bacterial acid production at the bacteria/tooth interface. The SDF-coated RD had the strongest inhibitory effect.

CLINICAL SIGNIFICANCE

Coating RD with SDF could help to prevent root caries.

Cost-Effectiveness through the Dental-Health FRAMM Guideline for Caries Prevention among 12- to 15-Year-Olds in Sweden

Since 2008, FRAMM has been a guideline for caries prevention for all 3- to 15-year-olds in the Västra Götaland Region in Sweden and a predominant part is school-based fluoride varnish applications for all 12- to 15-year-olds. The aims were to evaluate dental health-economic data among 12- to 15-year-olds, based on the approximal caries prevalence at the age of 12, and to evaluate cost-effectiveness. Caries data for 13,490 adolescents born in 1993 who did not take part and 11,321 adolescents born in 1998 who followed this guideline were extracted from dental records. Those with no dentin and/or enamel caries lesions and/or fillings on the approximal surfaces were pooled into the “low” subgroup, those with 1–3 into the “moderate” subgroup and those with ≥4 into the “high” subgroup. The results revealed that the low subgroup had a low approximal caries increment compared with the moderate and high subgroups during the 4-year study period. In all groups, there were statistically significant differences between those who took part in the guideline and those who did not. The analysis of cost-effectiveness revealed the lowest incremental cost-effectiveness ratio (ICER) for the high subgroup for decayed and/or filled approximal surfaces (DFSa) and approximal enamel lesions together and the highest ICER for the low subgroup for DFSa alone. To conclude, the FRAMM Guideline reduced the caries increment for adolescents with low, moderate and high approximal caries prevalence. The subgroup with the most favourable cost-effectiveness comprised those with a high caries prevalence at the age of 12.

Scientific evidence for the management of dentin caries lesions in pediatric dentistry: A systematic review and network meta-analysis

BACKGROUND

A systematic quantitative evaluation of the available evidence of the treatment for caries lesions in primary teeth that considers how different caries progressions lead to the need for distinct interventions might provide additional useful information for clinical evidence-based decision making. The aim of this systematic review and network meta-analysis was to verify the effect of the treatments on caries lesion arrestment (CLA) or the success rate (SR) of dentin caries lesion treatments in the primary teeth.

METHODS

A search was conducted using the MEDLINE/PubMed, Web of Science and Scopus databases through December 2017. The primary search terms used in combination were primary teeth, caries lesion and restoration. The grey literature was also screened, as were the reference lists of eligible studies. A search of prospective studies with at least 12 months of follow up that compared different techniques was performed. The exclusion criteria were the absence of a comparison group; no evaluation of different restorative techniques; the evaluation of other outcomes unrelated to this review; and the recruitment of specific patient. The risk of bias was evaluated by the tools: the Cochrane Handbook for Systematic Reviews of Interventions and ROBINS-I. A network meta-analyses and meta-analyses were conducted considering CLA or SR as outcomes according to the surface involved and the depth of progression.

RESULTS

Of the 1671 potentially eligible studies, 15 were included. For occlusal surfaces, only two studies presented data regarding the outer half of the dentin, with conventional restorative treatment (CRT) using composite resin showing superior results; five studies presented data regarding the depth of caries lesions, and CRT with compomer resulted in the best results. Seven studies considered occlusoproximal surfaces, and the Hall technique showed the best SR among the evaluated treatments. Finally, two annual applications of silver diamine fluoride showed the best nonrestorative approach to arrest caries lesions on occlusal and smooth surfaces.

DISCUSSION/CONCLUSIONS

The treatments for dentin caries lesions in primary teeth depend on the depth of progression and the surface involved. However, few of the included studies provided evidence to strongly recommend the best treatment option.

OTHER

Funding: FAPESP; Systematic review registration number-PROSPERO CRD42016037784.

Enhancing predicted fluoride varnish efficacy and post-treatment compliance by means of calcium-containing gummy bears

OBJECTIVES

This study determined whether consumption of calcium-containing gummies prior to fluoride varnish application enhances plaque fluoride retention and compliance with post-varnish application instructions.

METHODS

The present study followed a multi-center, parallel, randomized, and laboratory analyst-blind design. Following IRB approval, parent consent and child assent, 44 subjects (7-12 years), were randomized to either gummy or no-gummy study groups. A baseline plaque sample was obtained after a wash-out period. Fluoride varnish (5% NaF) was applied; subjects in the gummy group received two calcium-containing gummies prior to varnish application. Subjects were given two questionnaires to complete (subject and parent) to investigate adherence to post-treatment instructions. Three days later, a second plaque sample was obtained. Plaque was analyzed for plaque fluid and solid fluoride concentrations. Fluoride data were analyzed using Wilcoxon Rank Sum tests, questionnaire data using Pearson chi-square tests.

RESULTS

Plaque fluid fluoride did not change pre- to post-treatment in the gummy group (mean ± sd: 8.8 ± 5.7 μmol/l vs. 10.0 ± 6.3 μmol/l; p = 0.265) or in the no-gummy group (8.1 ± 4.4 μmol/l vs. 16.1 ± 20.0 μmol/l; p = 0.058). Groups were not different for plaque fluid fluoride pre-treatment (p = 1.000), post-treatment (p = 0.904), or change (p = 0.904). Plaque solid fluoride did not change pre- to post-treatment in the gummy group (0.89 ± 1.10 μmol/g vs. 1.37 ± 1.77 μmol/g; p = 0.073) or in the no-gummy group (0.68 ± 0.77 μmol/g vs. 2.01 ± 5.00 μmol/g; p = 0.190). Groups were not different for plaque solid fluoride pre-treatment (p = 1.000), post-treatment (p = 0.466), or change (p = 0.874). No significant differences were found between groups for questionnaire responses.

CONCLUSION

This study failed to demonstrate an effect of calcium-containing gummies in enhancing plaque fluoride retention.

CLINICAL SIGNIFICANCE

The consumption of calcium-containing gummies prior to fluoride varnish application does not promote greater intra-oral fluoride retention or better adherence to post-treatment instructions.

Biomimetic Tooth Repair: Amelogenin-Derived Peptide Enables in Vitro Remineralization of Human Enamel

White spot lesions (WSL) and incipient caries on enamel surfaces are the earliest clinical outcomes for demineralization and caries. If left untreated, the caries can progress and may cause complex restorative procedures or even tooth extraction which destroys soft and hard tissue architecture as a consequence of connective tissue and bone loss. Current clinical practices are insufficient in treating dental caries. A long-standing practical challenge associated with demineralization related to dental diseases is incorporating a functional mineral microlayer which is fully integrated into the molecular structure of the tooth in repairing damaged enamel. This study demonstrates that small peptide domains derived from native protein amelogenin can be utilized to construct a mineral layer on damaged human enamel in vitro. Six groups were prepared to carry out remineralization on artificially created lesions on enamel: (1) no treatment, (2) Ca²⁺ and PO₄^3- only, (3) 1100 ppm fluoride (F), (4) 20 000 ppm F, (5) 1100 ppm F and peptide, and (6) peptide alone. While the 1100 ppm F sample (indicative of common F content of toothpaste for homecare) did not deliver F to the thinly deposited mineral layer, high F test sample (indicative of clinical varnish treatment) formed mainly CaF₂ nanoparticles on the surface. Fluoride, however, was deposited in the presence of the peptide, which also formed a thin mineral layer which was partially crystallized as fluorapatite. Among the test groups, only the peptide-alone sample resulted in remineralization of fairly thick (10 μm) dense mineralized layer containing HAp mineral, resembling the structure of the healthy enamel. The newly formed mineralized layer exhibited integration with the underlying enamel as evident by cross-sectional imaging. The peptide-guided remineralization approach sets the foundation for future development of biomimetic products and treatments for dental health care.

A randomised controlled trial to measure the effects and costs of a dental caries prevention regime for young children attending primary care dental services: the Northern Ireland Caries Prevention In Practice (NIC-PIP) trial

BACKGROUND

Dental caries is the most common disease of childhood. The NHS guidelines promote preventative care in dental practices, particularly for young children. However, the cost-effectiveness of this policy has not been established.

OBJECTIVE

To measure the effects and costs of a composite fluoride intervention designed to prevent caries in young children attending dental services.

DESIGN

The study was a two-arm, parallel-group, randomised controlled trial, with an allocation ratio of 1 : 1. Randomisation was by clinical trials unit, using randomised permuted blocks. Children/families were not blinded; however, outcome assessment was blinded to group assessment.

SETTING

The study took place in 22 NHS dental practices in Northern Ireland, UK.

PARTICIPANTS

The study participants were children aged 2-3 years, who were caries free at baseline.

INTERVENTIONS

The intervention was composite in nature, comprising a varnish containing 22,600 parts per million (p.p.m.) fluoride, a toothbrush and a 50-ml tube of toothpaste containing 1450 p.p.m. fluoride; plus standardised, evidence-based prevention advice provided at 6-monthly intervals over 3 years. The control group received the prevention advice alone.

MAIN OUTCOME MEASURES

The primary outcome measure was conversion from caries-free to caries-active states. Secondary outcome measures were the number of decayed, missing or filled tooth surfaces in primary dentition (dmfs) in caries-active children, the number of episodes of pain, the number of extracted teeth and the costs of care. Adverse reactions (ARs) were recorded.

RESULTS

A total of 1248 children (624 randomised to each group) were recruited and 1096 (549 in the intervention group and 547 in the control group) were included in the final analyses. A total of 87% of the intervention children and 85% of control children attended every 6-month visit (p = 0.77). In total, 187 (34%) children in the intervention group converted to caries active, compared with 213 (39%) in the control group [odds ratio (OR) 0.81, 95% confidence interval (CI) 0.64 to 1.04; p = 0.11]. The mean number of tooth surfaces affected by caries was 7.2 in the intervention group, compared with 9.6 in the control group (p = 0.007). There was no significant difference in the number of episodes of pain between groups (p = 0.81). However, 164 out of the total of 400 (41%) children who converted to caries active reported toothache, compared with 62 out of 696 (9%) caries-free children (OR 7.1 95% CI 5.1 to 9.9; p < 0.001). There was no statistically significant difference in the number of teeth extracted in caries-active children (p = 0.95). Ten children in the intervention group had ARs of a minor nature. The average direct dental care cost was £155.74 for the intervention group and £48.21 for the control group over 3 years (p < 0.05). The mean cost per carious surface avoided over the 3 years was estimated at £251.00.

LIMITATIONS

The usual limitations of a trial such as generalisability and understanding the underlying reasons for the outcomes apply. There is no mean willingness-to-pay threshold available to enable assessment of value for money.

CONCLUSIONS

A statistically significant effect could not be demonstrated for the primary outcome. Once caries develop, pain is likely. There was a statistically significant difference in dmfs in caries-active children in favour of the intervention. Although adequately powered, the effect size of the intervention was small and of questionable clinical and economic benefit.

FUTURE WORK

Future work should assess the caries prevention effects of interventions to reduce sugar consumption at the population and individual levels. Interventions designed to arrest the disease once it is established need to be developed and tested in practice.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN36180119 and EudraCT 2009-010725-39.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 71. See the NIHR Journals Library website for further project information.

Revitalising Silver Nitrate for Caries Management

Silver nitrate has been adopted for medical use as a disinfectant for eye disease and burned wounds. In dentistry, it is an active ingredient of Howe’s solution used to prevent and arrest dental caries. While medical use of silver nitrate as a disinfectant became subsidiary with the discovery of antibiotics, its use in caries treatment also diminished with the use of fluoride in caries prevention. Since then, fluoride agents, particularly sodium fluoride, have gained popularity in caries prevention. However, caries is an infection caused by cariogenic bacteria, which demineralise enamel and dentine. Caries can progress and cause pulpal infection, but its progression can be halted through remineralisation. Sodium fluoride promotes remineralisation and silver nitrate has a profound antimicrobial effect. Hence, silver nitrate solution has been reintroduced for use with sodium fluoride varnish to arrest caries as a medical model strategy of caries management. Although the treatment permanently stains caries lesions black, this treatment protocol is simple, painless, non-invasive, and low-cost. It is well accepted by many clinicians and patients and therefore appears to be a promising strategy for caries control, particularly for young children, the elderly, and patients with severe caries risk or special needs.

Efficacy of Fluoride Varnishes with Added Calcium Phosphate in the Protection of the Structural and Mechanical Properties of Enamel

The aim of this study was to investigate the efficacy of various fluoride varnishes in the protection of the structural and nanomechanical properties of dental enamel. Demineralized enamel specimens were imaged using a high-resolution micro-CT system and lesion parameters including mineral density and lesion depth were extracted from mineral density profiles. Nanoindentation elastic modulus and hardness were calculated as a function of penetration depth from the load-displacement curves. The average depth of the lesion in specimens with no prior fluoride varnish treatment was 86 ± 7.19 μm whereas the varnish treated specimens had an average depth of 67 ± 7.03 μm (P < 0.05). The mineral density of enamel lesions with no fluoride varnish treatment had an average of 1.85 gr/cm3 which was 25% lower than the corresponding value in varnish treated enamel and 37% lower than sound enamel. While, in the varnish treated group, elastic modulus and hardness values had decreased by 18% and 23%, respectively, the corresponding values in the non-varnish treated specimens had a reduction of 43% and 54% compared to the sound enamel. The findings from this study highlight the preventive role of fluoride varnishes. Addition of calcium and phosphate does not seem to enhance or inhibit the prevention or remineralization performance of fluoride varnishes.

The history of public health use of fluorides in caries prevention

AIM

The aim of our study was to chronologically analyse various public health measures of fluoride use in caries prevention.

METHODS

We systematically searched the PubMed database on the preventive role of fluorides in public health, published from 1984 to 2014. The search process was divided into four steps, where inclusion and exclusion criteria were defined. Qualitative methodology was used for the article analysis. In the research process, the described forms of F use, diversity of the described F agents, and the observed population group were analysed.

RESULTS

In our systematic review, 40 relevant reviews were revealed. Fluorides have been used in many different forms, but only a few studies showed their significant role in public health. Water fluoridation was the most important public health measure. In the recent decades, the number of studies on topical fluorides is constantly rising. The most extensively described topical forms of fluorides are professionally applied fluoride agents and fluoride toothpaste for home-use. The use of fluoride containing toothpaste in caries prevention is a safe and successful public health measure (PHM) if their use is widespread, and it is recommended for all. The results on other topical forms of fluorides are insufficient to be suggested as an important PHM.

CONCLUSIONS

The role of fluorides in public health prevention has changed in accordance with the knowledge about the fluoride cariostatic mechanism. Previously the most important pre-eruptive effect of fluorides was supplemented by the post eruptive effect. Abundant evidence exists to show the effectiveness of systemic and topical fluorides.

Role of fluoride varnish in preventing early childhood caries: A systematic review

Background:

Early childhood caries is a public health problem that continues to affect babies and preschool children worldwide. This untreated caries process results in progressive destruction of the crowns of the teeth, often accompanied by severe pain and suffering, affecting the quality of life. Fluoride varnish which is one of the most important materials to prevent ECC is easy to apply and well tolerated by children. This study aimed to evaluate the scientific evidence regardingthe role of fluoride varnish in preventing early childhood caries.

Materials and Methods:

Records were searched from various databases such as PubMed/Medline, Cochrane, and EMBASE. Articles published over the past 36 years (1979-2015) were identified using the key search terms. A total of 190 records were identified by title/abstracts/full text articles and were retrieved. Potentially relevant reports identified from the reference lists of relevant studies, review articles and chapters were hand-searched, which yielded an additional 10 articles. The main outcome of our investigation was prevention of early childhood caries following application of fluoride varnish and unavoidable fluoride exposure. Out of 190 articles originally identified, 30 records were considered potentially eligible and sought for further assessment. 17 articles met the inclusion criteria and these studies were assessed independently for methodology and performance.

Results:

Analysis of literature revealed that basically two concentrations of fluoride varnishes have been used: 1% and 5%, with a caries preventive fraction ranges of 6.4-30% and 5-63%, respectively.

Conclusion:

The results showed that fluoride varnishes have been used at concentrations of 1% and 5% in the prevention of ECC. The preventive fraction was influenced by the frequency of application, the duration of study and sample size. The evidence level of the studies was of moderate to limited value.

Control of White Spot Lesions with Use of Fluoride Varnish or Chlorhexidine Gel During Orthodontic Treatment A Randomized Clinical Trial

OBJECTIVE

To compare the effectiveness of fluoride varnish and 2% chlorhexidine gel for controlling active white spot lesions (WSLs) adjacent to orthodontic brackets.

STUDY DESIGN

Thirty-five orthodontic patients (17.2 ± 2.3 years old) presenting 60 WSLs adjacent to orthodontic brackets were enrolled in this randomized, blind, 3-armed and controlled clinical trial. The patients were randomly allocated to 1 of 3 arms: (1) two applications of 5% NaF varnish- F, with one-week interval, (2) two applications of 2% chlorhexidine gel-CHX, with one-week interval and (3) usual home care-control (CO). The WSLs were scored by using a DIAGNOdent pen. An independent examiner scored the surfaces using Nyvad criteria for caries assessment.

RESULTS

A total of thirty patients presenting 51 lesions completed the study. All treatments reduced the fluorescence values during the experimental period; however, F induced faster remineralization than CHX. After 3 months, 70.58 % were inactive considering all groups. DIAGNOdent pen and Nyvad presented a significant correlation.

CONCLUSION

After 3 months of treatment, F, CHX and CO were capable of controlling the WSLs adjacent to the orthodontic brackets. However, the treatment with F was capable of controlling the progression of the WSLs in a shorter period of time.

Fluoride mouthrinses for preventing dental caries in children and adolescents

BACKGROUND

Fluoride mouthrinses have been used extensively as a caries-preventive intervention in school-based programmes and by individuals at home. This is an update of the Cochrane review of fluoride mouthrinses for preventing dental caries in children and adolescents that was first published in 2003.

OBJECTIVES

The primary objective is to determine the effectiveness and safety of fluoride mouthrinses in preventing dental caries in the child and adolescent population.The secondary objective is to examine whether the effect of fluoride rinses is influenced by:• initial level of caries severity;• background exposure to fluoride in water (or salt), toothpastes or reported fluoride sources other than the study option(s); or• fluoride concentration (ppm F) or frequency of use (times per year).

SEARCH METHODS

We searched the following electronic databases: Cochrane Oral Health's Trials Register (whole database, to 22 April 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2016, Issue 3), MEDLINE Ovid (1946 to 22 April 2016), Embase Ovid (1980 to 22 April 2016), CINAHL EBSCO (the Cumulative Index to Nursing and Allied Health Literature, 1937 to 22 April 2016), LILACS BIREME (Latin American and Caribbean Health Science Information Database, 1982 to 22 April 2016), BBO BIREME (Bibliografia Brasileira de Odontologia; from 1986 to 22 April 2016), Proquest Dissertations and Theses (1861 to 22 April 2016) and Web of Science Conference Proceedings (1990 to 22 April 2016). We undertook a search for ongoing trials on the US National Institutes of Health Trials Register (http://clinicaltrials.gov) and the World Health Organization International Clinical Trials Registry Platform. We placed no restrictions on language or date of publication when searching electronic databases. We also searched reference lists of articles and contacted selected authors and manufacturers.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials where blind outcome assessment was stated or indicated, comparing fluoride mouthrinse with placebo or no treatment in children up to 16 years of age. Study duration had to be at least one year. The main outcome was caries increment measured by the change in decayed, missing and filled tooth surfaces in permanent teeth (D(M)FS).

DATA COLLECTION AND ANALYSIS

At least two review authors independently performed study selection, data extraction and risk of bias assessment. We contacted study authors for additional information when required. The primary measure of effect was the prevented fraction (PF), that is, the difference in mean caries increments between treatment and control groups expressed as a percentage of the mean increment in the control group. We conducted random-effects meta-analyses where data could be pooled. We examined potential sources of heterogeneity in random-effects metaregression analyses. We collected adverse effects information from the included trials.

MAIN RESULTS

In this review, we included 37 trials involving 15,813 children and adolescents. All trials tested supervised use of fluoride mouthrinse in schools, with two studies also including home use. Almost all children received a fluoride rinse formulated with sodium fluoride (NaF), mostly on either a daily or weekly/fortnightly basis and at two main strengths, 230 or 900 ppm F, respectively. Most studies (28) were at high risk of bias, and nine were at unclear risk of bias.From the 35 trials (15,305 participants) that contributed data on permanent tooth surface for meta-analysis, the D(M)FS pooled PF was 27% (95% confidence interval (CI), 23% to 30%; I(2) = 42%) (moderate quality evidence). We found no significant association between estimates of D(M)FS prevented fractions and baseline caries severity, background exposure to fluorides, rinsing frequency or fluoride concentration in metaregression analyses. A funnel plot of the 35 studies in the D(M)FS PF meta-analysis indicated no relationship between prevented fraction and study precision (no evidence of reporting bias). The pooled estimate of D(M)FT PF was 23% (95% CI, 18% to 29%; I² = 54%), from the 13 trials that contributed data for the permanent teeth meta-analysis (moderate quality evidence).We found limited information concerning possible adverse effects or acceptability of the treatment regimen in the included trials. Three trials incompletely reported data on tooth staining, and one trial incompletely reported information on mucosal irritation/allergic reaction. None of the trials reported on acute adverse symptoms during treatment.

AUTHORS' CONCLUSIONS

This review found that supervised regular use of fluoride mouthrinse by children and adolescents is associated with a large reduction in caries increment in permanent teeth. We are moderately certain of the size of the effect. Most of the evidence evaluated use of fluoride mouthrinse supervised in a school setting, but the findings may be applicable to children in other settings with supervised or unsupervised rinsing, although the size of the caries-preventive effect is less clear. Any future research on fluoride mouthrinses should focus on head-to-head comparisons between different fluoride rinse features or fluoride rinses against other preventive strategies, and should evaluate adverse effects and acceptability.

Minimal intervention dentistry II: part 3. Management of non-cavitated (initial) occlusal caries lesions--non-invasive approaches through remineralisation and therapeutic sealants

Epidemiological data on dental caries show that prevention and treatment needs have evolved significantly over the past two decades. In younger patients the distribution of caries lesions is mainly found on the occlusal surfaces. The treatment approaches utilised by dentists must evolve to integrate preventive and treatment solutions tailored to the care needs, which are straightforward to implement in the dental office and whose effectiveness is underpinned by scientific evidence. This article aims to describe the principles of non-invasive management of non-cavitated (initial) occlusal caries lesions, based on evidence from recent studies published in the international literature.

EAPD interim seminar and workshop in Brussels May 9 2015 : Non-invasive caries treatment

Aim

This was to collect information for the 9th European Academy of Paediatric Dentistry Interim Seminar and Workshops to discuss the state of art on non-invasive caries therapy to be used if possible to formulate clinical guidelines by European experts in paediatric dentistry

Methods

Based on systematic reviews and additional papers were assessed for methods to prevent caries initiation and caries progression both in the state of pre-cavitation and cavitation without invasive technologies.

Results

The use of fluoridated water, careful diligent daily use of fluoride toothpaste, fluoride varnishes, pit and fissure sealants and leak-proof restorative materials without excavation of caries are evidence based for caries prevention and for non-invasive treatment of pre-cavitated and cavitated caries. Other technologies are far less evidenced based and would not logically fit in guidelines for the non-invasive treatment of caries. Recent studies on cavitated lesions in the primary dentition demonstrate that thorough oral hygiene practices may arrest progression. This strategy depends heavily on the strategies in the dental surgery to change behaviour of children. An important aspect is for advice to be tailored at recall intervals to ensure compliance and to timely detect unnecessary and unwanted progression of the lesions.

Conclusion

Non-invasive therapies have been proven to be effective for caries prevention and the management of pre-cavitated caries lesions. Non-invasive therapies can also be effective to arrest cavitated lesions but the success depends greatly on behavioural changes of patients to brush the lesions.

Pit and fissure sealants versus fluoride varnishes for preventing dental decay in the permanent teeth of children and adolescents

BACKGROUND

Most of the detected increment in dental caries among children and adolescents is confined to occlusal surfaces of posterior permanent molars. Dental sealants and fluoride varnishes are much used preventive options for caries. Although the effectiveness of sealants and fluoride varnishes for controlling caries as compared with no intervention has been demonstrated in clinical trials and summarised in systematic reviews, the relative effectiveness of these two interventions remains unclear. This review is an update of one first published in 2006 and last updated in 2010.

OBJECTIVES

Primary objective • To evaluate the relative effectiveness of fissure sealants compared with fluoride varnishes, or fissure sealants together with fluoride varnishes compared with fluoride varnishes alone, for preventing dental caries in the occlusal surfaces of permanent teeth of children and adolescents. Secondary objectives • To evaluate whether effectiveness is influenced by sealant material type and length of follow-up.• To document and report on data concerning adverse events associated with sealants and fluoride varnishes.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (to 18 December 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 11), MEDLINE via Ovid (1946 to 18 December 2015) and EMBASE via Ovid (1980 to 18 December 2015). We also searched the US National Institutes of Health Trials Register (http://clinicaltrials.gov) and the World Health Organization (WHO) Clinical Trials Registry Platform for ongoing trials. We placed no restrictions on language or date of publication when searching electronic databases. We screened the reference lists of identified trials and review articles for additional relevant studies.

SELECTION CRITERIA

We included randomised controlled trials with at least 12 months of follow-up comparing fissure sealants, or fissure sealants together with fluoride varnishes, versus fluoride varnishes for preventing caries in the occlusal surfaces of permanent premolar or molar teeth, in participants younger than 20 years of age at the start of the study.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results, extracted data and assessed risk of bias of included studies. We attempted to contact study authors to obtain missing or unclear information.We grouped and analysed studies on the basis of sealant material type (resin-based sealant and glass ionomer-based sealant: glass ionomer and resin-modified glass ionomer) and different follow-up periods. We calculated the odds ratio (OR) for caries or no caries on occlusal surfaces of permanent molar teeth. For trials with a split-mouth design, we used the Becker-Balagtas odds ratio. For continuous outcomes and data, we used means and standard deviations to obtain mean differences. We presented all measures with 95% confidence intervals (CIs).We assessed the quality of the evidence using GRADE (Grades of Recommendation, Assessment, Development and Evaluation) methods.We conducted meta-analysis using the fixed-effect model, as data from only two studies were combined. We had planned to conduct meta-analyses using a random-effects model when more than three trials were included in the meta-analysis.

MAIN RESULTS

In this review, we included eight trials with 1746 participants (four of the trials were new since the 2010 update). Seven trials (1127 participants) contributed to the analyses, and children involved were five to 10 years of age at the start of the trial. Sealant versus fluoride varnish Resin-based fissure sealants compared with fluoride varnishes Four trials evaluated this comparison (three of them contributing to the analyses). Compared with fluoride varnish, resin-based sealants prevented more caries in first permanent molars at two-year follow-up (two studies in the meta-analysis with pooled odds ratio (OR) 0.69, 95% confidence interval (CI) 0.50 to 0.94; P value = 0.02; I(2) = 0%; 358 children evaluated). We assessed the body of evidence as low quality. The caries-preventive benefit for sealants was maintained at longer follow-up in one trial at high risk of bias: 26.6% of sealant teeth and 55.8% of fluoride-varnished teeth had developed caries when 75 children were evaluated at nine years of follow-up. Glass ionomer-based sealants compared with fluoride varnishes Three trials evaluated this comparison: one trial with chemically cured glass ionomer and two with resin-modified glass ionomer. Researchers reported similar caries increment between study groups regardless of which glass ionomer material was used in a trial. Study designs were clinically diverse, and meta-analysis could not be conducted. The body of evidence was assessed as of very low quality. Sealant together with fluoride varnish versus fluoride varnish alone One split-mouth trial analysing 92 children at two-year follow-up found a significant difference in favour of resin-based fissure sealant together with fluoride varnish compared with fluoride varnish only (OR 0.30, 95% CI 0.17 to 0.55). The body of evidence was assessed as low quality. Adverse events Three trials (two with resin-based sealant material and one with resin-modified glass ionomer) reported that no adverse events resulted from use of sealants or fluoride varnishes. The other five studies did not mention adverse events.

AUTHORS' CONCLUSIONS

Currently, scarce and clinically diverse data are available on the comparison of sealants and fluoride varnish applications; therefore it is not possible to draw clear conclusions about possible differences in effectiveness for preventing or controlling dental caries on occlusal surfaces of permanent molars. The conclusions of this updated review remain the same as those of the last update (in 2010). We found some low-quality evidence suggesting the superiority of resin-based fissure sealants over fluoride varnish applications for preventing occlusal caries in permanent molars, and other low-quality evidence for benefits of resin-based sealant and fluoride varnish over fluoride varnish alone. Regarding glass ionomer sealant versus fluoride varnish comparisons, we assessed the quality of the evidence as very low and could draw no conclusions.

[Comparison of varnishes and fluoridated toothpaste for the prevention of dental caries in school children]

Objective To compare preventive effect on dental caries of two frequencies of fluoridated varnish (FV) applications and a group given brushing instructions and using fluoridated toothpaste. Materials and Methods Follow-up study of 203 children attending an elementary school in the municipality of Tláhuac, Mexico City. The children were followed for 22 months. The students were randomly assigned to one of the following groups: 1) brushing instructions with fluoridated toothpaste, 2) FV every six months, 3) three FV applications per week per year. The FV contained fluorosilane (1000 ppm F) and NaF dentifrice (1450 ppm F). The DMFT-caries index and the presence of white spots were recorded (ICDAS, International Caries Detection and Assessment System). Results At baseline, the mean age of the children was 9.3 (SD 0.76) years, white lesions 0.63 (SD 1.48) and DMFT =0.70 (SD 1.11). Averages of the initial and final DMFT scores in the three groups were 0.67 and 1.17 for the toothpaste group, 0.77 and 1.46 for FV twice a year group, and 0.67 y 1.03 for the three-applications-FV group. According to the results of the GEE (Generalized-Estimating Equations) model, there were no significant differences in the rate of white lesions or the increase of the DMFT index. The results for the DMFT were: for bi-annual applications of FV, RR=1.24 (p=0.178) and for the three consecutive applications of FV, RR=0.83, (p=0.298) in comparison with the brushing-instructions group using fluoridated toothpaste, among the three treatment groups, controlling for age, sex, and initial-caries index in primary teeth and brushing frequency. Conclusions Schoolchildren showed a low incidence of caries using any of the three preventive regimens applied.

The evidence base for professional and self-care prevention--caries, erosion and sensitivity

BACKGROUND

The aim of this conference paper was to examine the evidence base for primary and secondary prevention of dental caries, erosions and dentin hypersensitivity through professional and self-care measures.

METHODS

A mapping of systematic reviews (SR) of literature was carried out in PubMed and the Cochrane library through April 2014 using established MeSH-terms and disease-related search words in various combinations. The search was restricted to SR's published in English or Scandinavian and all age groups were considered. The reference lists of the selected papers were hand-searched for additional review articles of potential interest. Meta-analyses, guidelines and treatment recommendations were considered only when SR's were lacking. In the event of updates or multiple systematic reviews covering the same topic, only the most recent article was included. No quality assessment of the systematic reviews was carried out. The quality of evidence was rated in four levels according to the GRADE scale.

RESULTS

In total, 39 SR were included. For primary caries prevention, the quality of evidence was high for the use of fluoride toothpaste (with and without triclosan) and moderate for fluoride varnish and fissure sealants. The quality of evidence for fluoride gel, fluoride mouth rinse, xylitol gums and silver diamine fluoride (SDF) was rated as low. For secondary caries prevention and caries arrest, only fluoride interventions and SDF proved consistent benefits, although the quality of evidence was low. Likewise, the GRADE score for preventing erosions located in the enamel with fluoride supplements was low. The quality of evidence for various professional and self-care methods to prevent and manage dentine hypersensitivity was very low.

CONCLUSIONS

There are knowledge gaps in many domains of cariology and preventive dentistry that must be addressed and bridged through clinical research of good quality.

Fluoride varnishes with calcium glycerophosphate: fluoride release and effect on in vitro enamel demineralization

The aims of this study were (1) to assess the amount of fluoride (F) released from varnishes containing calcium glycerophosphate (CaGP) and (2) to assess the effect of the experimental varnishes on in vitro demineralization. Six test groups using 5 varnishes: base varnish (no active ingredients); Duraphat® (2.26% NaF); Duofluorid® (5.63% NaF/CaF2); experimental varnish 1 (1% CaGP/5.63% NaF/CaF2); experimental varnish 2 (5% CaGP/5.63% NaF/CaF2); and no varnish were set up. In stage 1, 60 acrylic blocks were randomly distributed into 6 groups (n = 10). Then 300 µg of each varnish was applied to each block. The blocks were immersed in deionized water, which was changed after 1, 8, 12, 24, 48 and 72 hours. Fluoride concentration in the water was analyzed using a fluoride electrode. In stage 2, 60 bovine enamel samples were distributed into 6 groups (n = 10), and treated with 300 µg of the respective varnish. After 6 h the varnish was removed and the samples were subjected to a 7-day in vitro pH cycle (6 h demineralization/18 h remineralization per day). The demineralization was measured using surface hardness. The results showed that both experimental varnishes released more fluoride than Duofluorid® and Duraphat® (p < 0.05), but Duraphat® showed the best preventive effect by decreasing enamel hardness loss (p < 0.05). Therefore, we conclude that even though (1) the experimental varnishes containing CaGP released greater amounts of F, (2) they did not increase in the preventive effect against enamel demineralization.

Fluoride gels for preventing dental caries in children and adolescents

BACKGROUND

Topically applied fluoride gels have been widely used as a caries-preventive intervention in dental surgeries and school-based programmes for over three decades. This updates the Cochrane review of fluoride gels for preventing dental caries in children and adolescents that was first published in 2002.

OBJECTIVES

The primary objective is to determine the effectiveness and safety of fluoride gels in preventing dental caries in the child and adolescent population.The secondary objectives are to examine whether the effect of fluoride gels is influenced by the following: initial level of caries severity; background exposure to fluoride in water (or salt), toothpastes, or reported fluoride sources other than the study option(s); mode of use (self applied under supervision or operator-applied), and whether there is a differential effect between the tray and toothbrush methods of application; frequency of use (times per year) or fluoride concentration (ppm F).

SEARCH METHODS

We searched the Cochrane Oral Health Group Trials Register (to 5 November 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library 2014, Issue 11), MEDLINE via OVID (1946 to 5 November 2014), EMBASE via OVID (1980 to 5 November 2014), CINAHL via EBSCO (1980 to 5 November 2014), LILACS and BBO via the BIREME Virtual Health Library (1980 to 5 November 2014), ProQuest Dissertations and Theses (1861 to 5 November 2014) and Web of Science Conference Proceedings (1945 to 5 November 2014). We undertook a search for ongoing trials on ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform on 5 November 2014. We placed no restrictions on language or date of publication in the search of the electronic databases. We also searched reference lists of articles and contacted selected authors and manufacturers.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials where blind outcome assessment was stated or indicated, comparing topically applied fluoride gel with placebo or no treatment in children up to 16 years. The frequency of application had to be at least once a year, and study duration at least one year. The main outcome was caries increment measured by the change in decayed, missing and filled tooth surfaces in both permanent and primary teeth (D(M)FS and d(e/m)fs).

DATA COLLECTION AND ANALYSIS

At least two review authors independently performed study selection, data extraction and 'Risk of bias' assessment. We contacted study authors for additional information where required. The primary measure of effect was the prevented fraction (PF), that is, the difference in mean caries increments between the treatment and control groups expressed as a percentage of the mean increment in the control group. We performed random-effects meta-analyses where we could pool data. We examined potential sources of heterogeneity in random-effects metaregression analyses. We collected adverse effects information from the included trials.

MAIN RESULTS

We included 28 trials (3 of which are new trials since the original review), involving 9140 children and adolescents. Most of these trials recruited participants from schools. Most of the studies (20) were at high risk of bias, with 8 at unclear risk of bias.Twenty-five trials (8479 participants) contributed data for meta-analysis on permanent tooth surfaces: the D(M)FS pooled prevented fraction (PF) estimate was 28% (95% confidence intervals (CI) 19% to 36%; P < 0.0001; with substantial heterogeneity (P < 0.0001; I(2) = 82%); moderate quality evidence). Subgroup and metaregression analyses suggested no significant association between estimates of D(M)FS prevented fractions and the prespecified trial characteristics. However, the effect of fluoride gel varied according to the type of control group used, with D(M)FS PF on average being 17% (95% CI 3% to 31%; P = 0.018) higher in non-placebo-controlled trials (the reduction in caries was 38% (95% CI 24% to 52%; P < 0.0001, 2808 participants) for the 10 trials with no treatment as control group, and 21% (95% CI 15% to 28%; P < 0.0001, 5671 participants) for the 15 placebo-controlled trials. A funnel plot of the 25 trials in the D(M)FS PF meta-analysis indicated a relationship between prevented fraction and study precision, with an apparent lack of small studies with statistically significant large effects.The d(e/m)fs pooled prevented fraction estimate for the three trials (1254 participants) that contributed data for the meta-analysis on primary teeth surfaces was 20% (95% CI 1% to 38%; P = 0.04; with no heterogeneity (P = 0.54; I(2) = 0%); low quality evidence).There was limited reporting of adverse events. Only two trials reported information on acute toxicity signs and symptoms during the application of the gel (risk difference 0.01, 95% CI -0.01 to 0.02; P = 0.36; with no heterogeneity (P = 36; I(2) = 0%); 490 participants; very low quality evidence). None of the trials reported information on tooth staining, mucosal irritation or allergic reaction.

AUTHORS' CONCLUSIONS

The conclusions of this updated review remain the same as those when it was first published. There is moderate quality evidence of a large caries-inhibiting effect of fluoride gel in the permanent dentition. Information concerning the caries-preventive effect of fluoride gel on the primary dentition, which also shows a large effect, is based on low quality evidence from only three placebo-controlled trials. There is little information on adverse effects or on acceptability of treatment. Future trials should include assessment of potential adverse effects.

Preventive care delivered within Public Dental Service after caries risk assessment of young adults

OBJECTIVES

To study preventive care provided to young adults in relation to their estimated risk category over a 3-year period.

METHODS

The amount and type of preventive treatment during 3 years was extracted from the digital dental records of 982 patients attending eight public dental clinics. The baseline caries risk assessment was carried out by the patient's regular team in four classes according to a predetermined model, and the team was responsible for all treatment decisions. Based on the variables 'oral health information', 'additional fluoride' and 'professional tooth cleaning', a cumulative score was constructed and dichotomized to 'basic prevention' and 'additional prevention'.

RESULTS

More additional preventive care was provided to the patients in the 'low-risk' and 'some risk' categories than to those classified as 'high' or 'very high' risk (OR = 2.0, 95% CI 1.4-3.0; P < 0.05). Professional tooth cleaning and additional fluorides were most frequently employed in the 'low-risk' and 'some risk' categories, respectively. Around 15% of the patients in the high-risk categories did not receive additional preventive measures over the 3-year period. There was an insignificant tendency that patients with additional prevention developed less caries than those that received basic prevention in all risk categories except for the 'very high-risk' group.

CONCLUSION

The caries risk assessment process was not accompanied by a corresponding targeted individual preventive care in a cohort of young adults attending public dental service. Further research is needed how to reach those with the greatest need of primary and secondary prevention.

A systematic map of systematic reviews in pediatric dentistry--what do we really know?

OBJECTIVES

To identify, appraise and summarize existing knowledge and knowledge gaps in practice-relevant questions in pediatric dentistry.

METHODS

A systematic mapping of systematic reviews was undertaken for domains considered important in daily clinical practice. The literature search covered questions in the following domains: behavior management problems/dental anxiety; caries risk assessment and caries detection including radiographic technologies; prevention and non-operative treatment of caries in primary and young permanent teeth; operative treatment of caries in primary and young permanent teeth; prevention and treatment of periodontal disease; management of tooth developmental and mineralization disturbances; prevention and treatment of oral conditions in children with chronic diseases/developmental disturbances/obesity; diagnosis, prevention and treatment of dental erosion and tooth wear; treatment of traumatic injuries in primary and young permanent teeth and cost-effectiveness of these interventions. Abstracts and full text reviews were assessed independently by two reviewers and any differences were solved by consensus. AMSTAR was used to assess the risk of bias of each included systematic review. Reviews judged as having a low or moderate risk of bias were used to formulate existing knowledge and knowledge gaps.

RESULTS

Out of 81 systematic reviews meeting the inclusion criteria, 38 were judged to have a low or moderate risk of bias. Half of them concerned caries prevention. The quality of evidence was high for a caries-preventive effect of daily use of fluoride toothpaste and moderate for fissure sealing with resin-based materials. For the rest the quality of evidence for the effects of interventions was low or very low.

CONCLUSION

There is an urgent need for primary clinical research of good quality in most clinically-relevant domains in pediatric dentistry.

Effect of fluoride varnish and chlorhexidine-thymol varnish on mutans streptococci levels in human dental plaque: a double-blinded randomized controlled trial

BACKGROUND

Recent systematic reviews on clinical trials comparing the efficacy of chlorhexidine and fluoride varnish found that the evidence was inconclusive and further well-conducted randomized controlled clinical trials were advocated.

AIM

To compare the effect of fluoride varnish (F) and Chlorhexidine-thymol varnish (CHX/T) with intensive application regimen on mutans streptococci (MS) levels in human dental plaque.

DESIGN

Seventy-five subjects between 6 and 10 years of age were allocated into three groups: Group 1-F varnish (n = 29); Group 2-CHX/T varnish(n = 29); Group 3-placebo varnish (n = 17) by stratified block randomization. After baseline plaque samples were obtained, varnish application was applied and repeated at an interval of 3 days in each group. Plaque samples were repeated at 48 h, 1 month, and 3 months. The samples were spread over mitis-salivarius-bacitracin (MSB) culture media, and the colony-forming units per ml (CFU) were measured.

RESULTS

In both Groups 1 and 2, Wilcoxon matched-pairs signed-rank test revealed significant differences in log CFU values of MS between baseline and 48 h, baseline and 1 month but no significant difference between baseline and 3 months. An intergroup comparison at different time intervals showed that the difference between three groups was statistically insignificant.

CONCLUSION

F varnish and CHX/T varnish, with an intensive regimen application have equivocal effect on MS levels in dental plaque.

Evaluation of fluoride release from experimental TiF4 and NaF varnishes in vitro

Fluoride varnishes play an important role in the prevention of dental caries, promoting the inhibition of demineralization and the increase of remineralization.

Biannual fluoride varnish applications and caries incidence in preschoolers: a 24-month follow-up randomized placebo-controlled clinical trial

Sound evidence on the effectiveness of fluoride varnishes (FV) to reduce caries incidence in preschool children is lacking.

OBJECTIVE

To assess whether the application of FV in preschool children at 6-month intervals decreases the incidence of caries and produces any adverse effects.

METHODS

A randomized, examiner- and patient-blind, placebo-controlled, parallel-group design, clinical trial, comprising 1- to 4-year-old children, 100 in each group (FV or placebo varnish, PV), was conducted in Rio de Janeiro, Brazil. Two trained pediatric dentists performed the clinical examinations (kappa = 0.85). Dental caries was recorded at the d2 (cavitated enamel) and d3 (dentine) levels using the International Caries Diagnosis and Assessment System.

RESULTS

At baseline, the mean age of the participants was 2.4 years (SD 0.9) and the mean d3mfs was 0.8 (SD 1.9). Most of the children brushed their teeth with fluoride toothpaste and consumed fluoridated tap water. After 24 months, 89 and 92 children of the test and the control groups were analyzed, respectively. A total of 32 (35.9%) children in the FV group and 43 (46.7%) in the PV group presented new dentine caries lesions (χ(2) test; p = 0.14), showing relative and absolute risk reductions of 23% (95% CI: -9.5 to 45.9) and 11% (95% CI: -3.5 to 25.0). The mean caries increment differences between the test and control groups were -0.8 (95% CI: -2.0 to 0.4) at the d2 level and -0.7 (95% CI: -1.9 to 0.4) at the d3 level. Only 2 minor complaints regarding the intervention were reported.

CONCLUSION

Although safe and well accepted, twice-yearly professional FV application, during 2 years, did not result in a significant decrease in caries incidence.

Substantial reduction in caries from regular fluoride varnish application

DATA SOURCES

The Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, CINAHL, LILACS and BBO, ProQuest Dissertations and Theses, Web of Science Conference Proceedings and ClinicalTrials.gov databases were searched. Reference lists of identified articles were also scanned for relevant papers. Study authors were contacted for additional information.

STUDY SELECTION

Randomised or quasi-randomised controlled trials using or indicating blind outcome assessment that compared fluoride varnish to placebo or no treatment for at least one year were included. Risk of bias assessment was undertaken.

DATA EXTRACTION AND SYNTHESIS

Study assessment and data extraction was carried out independently by at least two reviewers. The primary measure of effect was the prevented fraction, that is the difference in mean caries increments between the treatment and control groups expressed as a percentage of the mean increment in the control group. The caries increments nearest to three years were used from each included study. Random-effects meta-analyses were performed where data could be pooled. Potential sources of heterogeneity were examined in random-effects meta-regression analyses. Adverse effects information was collected from the included trials.

RESULTS

Twenty-two trials (12,455 participants) were included. Thirteen trials were included in the permanent tooth surfaces meta-analysis, the pooled D(M)FS prevented fraction estimate comparing fluoride varnish with placebo or no treatment was 43% (95% confidence interval (CI) 30% to 57%; P < 0.0001). There was substantial heterogeneity, confirmed statistically (P < 0.0001; I(2) = 75%), however this body of evidence was assessed as of moderate quality. Ten trials contributed to the meta-analysis of primary teeth, the pooled d(e/m)fs prevented fraction estimate was 37% (95% CI 24% to 51%; P < 0.0001), there was some heterogeneity (P = 0.009; I(2) = 59%) this evidence was assessed as of moderate quality. No significant associations in either dentitions were found with baseline caries severity, background exposure to fluorides, application features such as prior prophylaxis, concentration of fluoride or frequency of application. There was little information concerning possible adverse effects or acceptability of treatment.

CONCLUSIONS

The conclusions of this updated review remain the same as when it was first published. The review suggests a substantial caries inhibiting effect of fluoride varnish in both permanent and primary teeth; however the quality of the evidence was assessed as moderate, as it included mainly high risk of bias studies, with considerable heterogeneity.

Fluoride varnishes for preventing dental caries in children and adolescents

BACKGROUND

Topically-applied fluoride varnishes have been used extensively as an operator-applied caries-preventive intervention for over three decades. This review updates the first Cochrane review of fluoride varnishes for preventing dental caries in children and adolescents, which was first published in 2002.

OBJECTIVES

To determine the effectiveness and safety of fluoride varnishes in preventing dental caries in children and adolescents, and to examine factors potentially modifying their effect.

SEARCH METHODS

We searched the Cochrane Oral Health Group's Trials Register (to 13 May 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 4), MEDLINE via OVID (1946 to 13 May 2013), EMBASE via OVID (1980 to 13 May 2013), CINAHL via EBSCO (1980 to 13 May 2013), LILACS and BBO via the BIREME Virtual Health Library (1980 to 13 May 2013), ProQuest Dissertations and Theses (1861 to 13 May 2013), and Web of Science Conference Proceedings (1945 to 13 May 2013). A search for ongoing trials was undertaken on ClinicalTrials.gov on 13 May 2013. There were no restrictions on language or date of publication in the search of the electronic databases.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials with blind outcome assessment used or indicated, comparing topically-applied fluoride varnish with placebo or no treatment in children up to 16 years during at least one year. The main outcome was caries increment measured by the change in decayed, missing and filled tooth surfaces in both permanent (D(M)FS) and primary (d(e/m)fs) teeth.

DATA COLLECTION AND ANALYSIS

At least two review authors assessed all search results, extracted data and undertook risk of bias independently. Study authors were contacted for additional information. The primary measure of effect was the prevented fraction, that is the difference in mean caries increments between the treatment and control groups expressed as a percentage of the mean increment in the control group. The caries increments nearest to three years were used from each included study. Random-effects meta-analyses were performed where data could be pooled. Potential sources of heterogeneity were examined in random-effects meta-regression analyses. Adverse effects information was collected from the included trials.

MAIN RESULTS

Twenty-two trials with 12,455 participants randomised (9595 used in analyses) were included. For the 13 that contributed data for the permanent tooth surfaces meta-analysis, the pooled D(M)FS prevented fraction estimate comparing fluoride varnish with placebo or no treatment was 43% (95% confidence interval (CI) 30% to 57%; P < 0.0001). There was substantial heterogeneity, confirmed statistically (P < 0.0001; I(2) = 75%), however this body of evidence was assessed as of moderate quality. The pooled d(e/m)fs prevented fraction estimate was 37% (95% CI 24% to 51%; P < 0.0001) for the 10 trials that contributed data for the primary tooth surfaces meta-analysis, also with some heterogeneity (P = 0.009; I(2) = 59%). Once again this body of evidence was assessed as of moderate quality. No significant association between estimates of D(M)FS or d(e/m)fs prevented fractions and the pre-specified factors of baseline caries severity, background exposure to fluorides, application features such as prior prophylaxis, concentration of fluoride, frequency of application were found. There was also no significant association between estimates of D(M)FS or d(e/m)fs prevented fractions and the post hoc factors: whether a placebo or no treatment control was used, length of follow-up, or whether individual or cluster randomisation was used, in the meta-regression models. A funnel plot of the trials in the main meta-analyses indicated no clear relationship between prevented fraction and study precision. In both methods, power is limited when few trials are included. There was little information concerning possible adverse effects or acceptability of treatment.

AUTHORS' CONCLUSIONS

The conclusions of this updated review remain the same as those when it was first published. The review suggests a substantial caries-inhibiting effect of fluoride varnish in both permanent and primary teeth, however the quality of the evidence was assessed as moderate, as it included mainly high risk of bias studies, with considerable heterogeneity.

The role of fluoride in the preventive management of dentin hypersensitivity and root caries

Objective

The objectives were to bring light on fluoride to control dentin hypersensitivity (DHS) and prevent root caries.

Materials and methods

Search strategy included papers mainly published in PubMed, Medline from October 2000 to October 2011.

Results

Fluoride toothpaste shows a fair effect on sensitive teeth when combined with dentin fluid-obstructing agents such as different metal ions, potassium, and oxalates. Fluoride in solution, gel, and varnish give an instant and long-term relief of dentin and bleaching hypersensitivity. Combined with laser technology, a limited additional positive effect is achieved. Prevention of root caries is favored by toothpaste with 5,000 ppm F and by fluoride rinsing with 0.025–0.1 % F solutions, as the application of fluoride gel or fluoride varnish three to four times a year. Fluoride measures with tablets, chewing gum, toothpick, and flossing may be questioned because of unfavorable cost effectiveness ratio.

Conclusion

Most fluoride preparations in combination with dentin fluid obstruction agents are beneficial to reduce DHS. Prevention of root caries is favorable with higher fluoride concentrations in, e.g., toothpaste.

Clinical relevance

Fluoride is an effective agent to control DHS and to prevent root caries particularly when used in higher concentrations.