Caries development after substitution of supervised fluoride rinses and toothbrushings by unsupervised use of fluoride toothpaste

Caries Progression Rates Revisited: A Systematic Review

Caries progression seems to follow universal, predictable rates, depending largely on the caries severity in populations: the higher the caries severity, the higher the progression rates. Quantification of these rates would allow prediction of future caries increments. Our aim was to describe caries progression rates in the primary and permanent dentition in Western populations (not in lesions) of children and adolescents. Therefore, we systematically searched MEDLINE-PubMed, Embase, CINAHL, and the Cochrane library for studies reporting caries progression data. Eligibility criteria were reporting empirical data from at least 2 full-mouth dental caries examinations in a closed cohort during a follow-up of at least 3 y, a first examination after 1974, a second examination before the age of 22 y, caries assessed as dentine caries (d₃/D₃), and caries reported in dmfs/DMFS (decayed, missing, and filled surfaces), dmft/DMFT (decayed, missing, and filled teeth), or caries-free participants. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, we described the results for the primary and permanent dentition in a systematic review, performed a meta-analysis for the caries incidence rate in the permanent dentition, and conducted multivariate, hierarchical meta-regression analyses for the caries incidence rate and the increments in DMFS and DMFT. Of the 6,343 unique studies retrieved, 43 studies (56,376 participants) were included for systematic review and 32 for meta-analyses (39,429 participants). The annual decline in caries-free children in the permanent dentition ranged from 0.8% to 10.2%. The annual increment ranged from 0.07 to 1.77 in DMFS and from 0.06 to 0.73 in DMFT. The pooled caries incidence rate was 0.11 (0.09–0.13) per person-year at risk. Meta-regression analyses showed that the methods of individual studies influenced pooled caries incidence rates and increments in DMFS and DMFT. This should be taken into account in planning and evaluation of oral health care services. However, the caries incidence rate is promising for prediction of future caries increments in populations.

Effect of different frequencies of fluoride dentifrice and mouthrinse administration: an in situ study

The effect of a combination of topical fluoridation methods for inhibition of enamel demineralization in the face of a cariogenic challenge has not been clearly established. This in situ crossover study aimed to assess whether the addition of daily use of fluoride mouthrinse (FR) to that of fluoride dentifrice (FD) is equivalent to increasing the frequency of FD application in terms of the effect on enamel demineralization and fluoride content. Over 3 phases of 14 days each, 12 volunteers wore appliances containing enamel blocks exposed to a 20 % sucrose solution 8 times/day. During each phase the blocks underwent one of the following treatments: 2x/day FD, 2x/day FD + 1x/day FR, and 3x/day FD. The blocks were assessed for hardness and fluoride content. Three x/day FD did not differ from 2x/day + 1x/day FR, however it enhanced demineralization protection when compared to 2x/day FD. All treatments produced an increase in enamel fluoride content compared to no treatment (sound blocks) (p < 0.05), but the differences between them were not significant. The results of this study suggest that the daily use of fluoride mouthrinse combined with that of fluoride dentifrice has similar effects on enamel demineralization and fluoride content when compared to increasing the frequency of fluoride dentifrice use.

Fluoride rinsing and dental health inequalities in 11-year-old children: an evaluation of a supervised school-based fluoride rinsing programme in Edinburgh

OBJECTIVES

Previous studies have shown that fluoride mouthrinsing programmes are effective in reducing caries among children and adolescents. National surveys of child dental health in the UK confirm that there is variation in oral health. In particular, children of low socioeconomic status in Scotland have a disproportionately high share of dental disease. This study aimed to evaluate an existing school-based fluoride mouthrinsing programme on dental caries in populations stratified by socioeconomic status.

METHODS

A random sample of 1333 children surveyed by the National Dental Inspection Programme with average age 11.4 years was included in the study. Caries prevalence data were collected for the 661 rinsers and 672 nonrinsers. Chi-squared tests and t-tests were carried out to test differences in proportion and in mean D(3)MFT, respectively. The data were modelled using multilevel logistic regression, adjusting for age, sex, deprivation and rinse status.

RESULTS

There is a strong negative association between deprivation and prevalence of D(3)MFT = 0. There is no significant difference in prevalence of D(3)MFT between rinsers and nonrinsers, however, mean D(3)MFT is greater for nonrinsers within each deprivation category. After adjusting for age, sex and deprivation, the odds of a tooth being decayed missing or filled for a child who rinsed are 0.79 (0.64, 0.98) compared with those of a child who did not.

CONCLUSIONS

Fluoride rinsing can be effectively targeted at children from deprived areas through school-based initiatives. There are some difficulties in recruiting all children from the more deprived backgrounds, but overall reductions in D(3)MFT were observed.

Statistical Aspects of Design and Analysis of Clinical Trials for the Prevention of Caries

This paper considers the methods used in design and analysis of recent clinical trials of topical fluoride interventions designed to prevent the development of dental caries in children, with particular consideration given to issues related to cluster-randomized trials. Studies which met the inclusion criteria were recent clinical trials of topical fluoride interventions published since 1990, conducted in children under 16 years of age, with caries as the outcome variable. Papers not published in English were translated. Information was extracted from the published trial reports on the units of randomization and analysis. The papers were also studied to assess if reporting allowed the assessment of potential consent bias in cluster-randomized trials and the reproduction of sample size calculations. Fifteen trials published since 1990 were included, of which five were cluster randomized. Only 1 of the 5 accounted for the clustering in the analysis. For the other four trials, it was possible to calculate that values from 0.002 (for DMFS) and 0.08 (for being caries free) for the intracluster correlation coefficient within schools could result in statistically non-significant findings. 3 of the 5 cluster-randomized trials did not report the consenting procedure in enough detail to judge whether consent bias could be present. Only 1 of the total 15 trials reported a sample size calculation. In summary, researchers should be aware of the importance of correctly analyzing cluster-randomized data and thorough reporting of clinical trials according to the CONSORT guidelines.

One topical fluoride (toothpastes, or mouthrinses, or gels, or varnishes) versus another for preventing dental caries in children and adolescents

BACKGROUND

Topical fluorides in the form of toothpaste, mouthrinse, varnish and gel are effective caries preventive measures. However, there is uncertainty about the relative value of these interventions.

OBJECTIVES

To compare the effectiveness of one form of topical fluoride intervention with another when used for the prevention of dental caries in children.

SEARCH STRATEGY

We searched the Cochrane Oral Health Group's Trials Register (May 2000), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2000), MEDLINE (1966 to January 2000), plus several other databases. We handsearched journals, reference lists of articles and contacted selected authors and manufacturers.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials with blind outcome assessment, comparing fluoride varnish, gel, mouthrinse, or toothpaste with each other in children up to 16 years during at least 1 year. The main outcome was caries increment measured by the change in decayed, missing and filled tooth surfaces (D(M)FS).

DATA COLLECTION AND ANALYSIS

Inclusion decisions, quality assessment and data extraction were duplicated in a random sample of one third of studies, and consensus achieved by discussion or a third party. Authors were contacted for missing data. The primary measure of effect was the prevented fraction (PF) that is the difference in mean caries increments between the 'experimental' and 'control' groups expressed as a percentage of the mean increment in the control group. Random effects meta-analyses were performed where data could be pooled.

MAIN RESULTS

There were 17 studies included, and 15 contributed data for the meta-analyses. Fluoride toothpaste was not significantly different from mouthrinse (pooled DMFS PF 0%; 95% CI, -18% to 19%; p = 0.94), or gel (pooled DMFS PF 0%; 95% CI, -21% to 21%; p = 1), or both gel and mouthrinse (pooled DMFS PF 1%; 95% CI, -13% to 14%; p = 0.94); heterogeneity was substantial. Results from the single trial comparing toothpaste with varnish (in deciduous teeth) were inconclusive (dfs PF 5%; CI not obtainable). The pooled results from the comparisons of fluoride varnish with mouthrinse was a non-significant difference favouring varnish (DMFS PF 10%; 95% CI, -12% to 32%; p = 0.40), but this result was not robust to sensitivity analysis performed, and heterogeneity was considerable. Results from the single trial comparing varnish with gel (14%, 95% CI, -12% to 40%; p = 0.30) and the single trial comparing gel with mouthrinse (-14% DMFS PF; 95% CI, -40% to 12%; p = 0.30) were inconclusive (favoured varnish and mouthrinse respectively).

REVIEWER'S CONCLUSIONS

Fluoride toothpastes in comparison to mouthrinses or gels appear to have a similar degree of effectiveness for the prevention of dental caries in children. There is no clear suggestion that fluoride varnish is more effective than mouthrinses and the evidence for the comparative effectiveness of fluoride varnishes and gels, and mouthrinses and gels is inconclusive. No conclusions about adverse effects could be reached, because no data were reported on in the trials. Acceptance is likely to be greater for fluoride toothpaste.

Caries-preventive effect of fluoride toothpaste: a systematic review

With a questionnaire addressed to general dental practitioners in Sweden, the Swedish Council on Technology Assessment in Health Care launched a project group in 1999 to systematically review and evaluate the existing literature on various caries preventive methods. The aim of this article was to report findings concerning the caries preventive effect of fluoride toothpastes in various age groups, with special emphasis on fluoride concentration and supervised versus non-supervised brushing. A systematic search in electronic databases for articles published between 1966 and April 2003 was conducted with the inclusion criteria of a randomized or controlled clinical trial, at least 2 years follow-up and caries increment in the permanent (deltaDMFS/T) or primary (deltadmfs/t) dentition as endpoint. Out of 905 articles originally identified, 54 met the inclusion criteria. These studies were assessed independently by at least two reviewers and scored A-C according to predetermined criteria for methodology and performance. The measure of effect was the prevented fraction (PF), expressed as percent. The results revealed strong evidence (level 1) (i) for the caries preventive effect of daily use of fluoride toothpaste compared to placebo in the young permanent dentition (PF 24.9%), (ii) that toothpastes with 1,500 ppm of fluoride had a superior preventive effect compared with standard dentifrices with 1,000 ppm F in the young permanent dentition (PF 9.7%), and (iii) that higher caries reductions were recorded in studies with supervised toothbrushing compared with non-supervised (PF 23.3%). However, incomplete evidence (level 4) was found regarding the effect of fluoride toothpaste in the primary dentition. In conclusion, this review reinforced the importance of daily toothbrushing with fluoridated toothpastes for preventing dental caries, although long-term studies in age groups other than children and adolescents are still lacking.

Caries incidence in adolescents with low caries prevalence after cessation of weekly fluoride rinsing

The aim of this study was to determine whether cessation of weekly fluoride rinsing leads to an increase in caries incidence in a group of adolescents with low caries prevalence. Sixty randomly selected 12- to 14-year-olds were asked to stop rinsing at school (test group). After 3 years caries increment and caries progression were compared with an age- and sex-matched control group (n = 60), who continued to rinse weekly with a 0.2% sodium fluoride solution. All children in both groups had followed a school-based fluoride rinsing program from the age of 6 years. The mean (standard deviation) caries increment, including only open lesions, during the 3 years was 1.58 (1.73) in the test group and 1.48 (1.80) in the control group. The corresponding figures for incipient lesions were 3.13 (3.63) and 4.03 (4.23), respectively. The mean caries progression was 0.92 (1.34) in the test group and 0.72 (1.03) in the control group. None of these differences were statistically significant. Thus, this study showed that a cessation of weekly fluoride rinsing did not lead to an increase of caries incidence in a group of adolescents with low caries prevalence.

Treatment practices in caries prevention for 6-year-olds in Finland

OBJECTIVES

To evaluate caries-preventive treatment practices in relation to caries state and eruption of first permanent molars (FPMs) among 6-year-olds (n = 3489) examined and treated in public dental clinics in Helsinki during 1992.

METHODS

The study subjects were selected on the basis of their caries state using a two-point study design: the high-caries group (n = 99) had the greatest number of DT + dt, the cavity-free group (n = 32) had neither past nor present caries. Evaluation of dentists' caries-preventive treatment decisions was based on data from detailed personal oral health records.

RESULTS

In total, 22% of the high-caries patients (mean DT + dt 8.7; range 4-18) had been judged by their dentists as high-risk patients. Eruption of FPMs had no influence on dentists' judgement on caries risk. A subject's number of DT + dt had no influence on the intensity of preventive treatment given, but those with a high-risk judgement from a dentist received more preventive measures per visit than did other high-caries patients. For high-caries patients with erupting FPMs, three visits in 10 included preventive intervention other than sealants, compared to nine in the cavity-free group. Intensity of oral hygiene instruction correlated with presence of erupting FPMs, yet 86% of the patients with erupting FPMs had received no oral hygiene instruction.

CONCLUSIONS

Dentists should be encouraged to use standardized criteria, including data on caries state and eruption stage, in judging each patient's risk of caries to provide intensified caries-preventive treatment to those most in need.

Caries-risk assessment

Dental caries has a multifactorial aetiology in which there is an interplay of three principal factors: the host (saliva and teeth), the microflora (plaque), and the substrate (diet), and a fourth factor: time. There is no single test that takes into consideration all these factors and can accurately predict an individual's susceptibility to caries. The risk of dental caries can be evaluated by analysing and integrating several causative factors. These include caries experience (initial caries lesions and established caries defects, secondary caries and present caries activity), fluoride use, extent of plaque present, diet, bacterial and salivary activity and social and behavioural factors.

Prevention of early childhood caries

This paper reviews the methods used for the prevention of early childhood caries (ECC). The education of mothers or caregivers to promote healthy dietary habits in infants has been the main strategy used for the prevention of ECC. This review found that education has a modest impact on the development of ECC. While education should be promoted especially in high risk communities and population groups (low-income families and native populations), it should not be the only preventive strategy of ECC. Early screening for signs of caries development, starting from the first year of life, could identify infants and toddlers who are at risk of developing ECC and assist in providing information to parents about how to promote oral health and prevent the development of tooth decay. High risk children include those with early signs of ECC, poor oral hygiene, limited exposure to fluorides, and frequent exposure to sugary snacks and drinks. These children should be targeted with a professional preventive program that includes fluoride varnish application, fluoridated dentifrices, fluoride supplements, sealants, diet counseling, and chlorhexidine. Prevention of ECC also requires addressing the social and economic factors that face many families where ECC is endemic.