Effect of prior toothcleaning on bi-annual professional acidulated phosphate fluoride topical fluoride gel-tray treatments. Results after three years

Efficacy of fluoride gel in arresting active non-cavitated caries lesions: a randomized clinical trial

This study evaluated the efficacy of fluoride gel in arresting active non-cavitated caries lesions in permanent teeth. This randomized, triple-blind, placebo-controlled clinical trial randomized 100 schoolchildren aged 10.7 ± 2.2 years to test treatment (1.23% acidulated phosphate fluoride [APF] gel) or control treatment (placebo gel) for 4-6 applications at weekly intervals. Data collection included the visible plaque index, gingival bleeding index, visible plaque accumulation on the occlusal surfaces, eruption stage, and dental caries. The association between group and lesion arrestment was assessed using logistic regression, and estimates were adjusted for plaque accumulation over the lesion at baseline, surface type, and tooth type. Models were fitted using generalized estimating equations for accounting for the clustering of data (i.e., the same individual contributed > 1 lesion). Ninety-eight children completed the study (48 fluoride and 50 placebo). When all dental surfaces were analyzed, the likelihood of lesion arrestment was similar between both groups (p > 0.05). A secondary analysis including only the occlusal lesions in molars showed that for teeth under eruption, lesions receiving the 1.23% APF gel were about 3-fold more likely to become arrested than lesions receiving the placebo gel (OR = 2.85; 95%CI = 1.23-6.61; p = 0.01). No significant difference was detected for molars with complete eruption (p > 0.05). The benefit of fluoride gel for arresting non-cavitated caries lesions could not be identified by clinical assessment in this short-term trial. Notwithstanding, when the cariogenic challenge was greater (as on the occlusal surfaces of erupting molars), 1.23% APF gel treatment was an important tool for caries control.

A systematic review of professional mechanical plaque removal for prevention of periodontal diseases

AIM

To investigate the effect of professional mechanical plaque removal (PMPR) on the prevention of periodontal diseases.

METHODS

We searched for randomized controlled trials, controlled clinical trials and cohort studies from 1950 to October 2004. Screening and data abstraction were conducted independently and in duplicate. Critical appraisal of studies was based on objective criteria and evidence tables were constructed.

RESULTS

From 2179 titles and abstracts, 132 full-text articles were screened and 32 studies were relevant. Evidence exists that PMPR in adults, particularly in combination with oral hygiene instruction (OHI), may be more effective than no treatment judged by surrogate measures. The evidence for a benefit of PMPR+OHI over OHI alone is less clear. The optimum frequency of PMPR has not been investigated although more frequent PMPR is associated with improved markers of health. The strength of evidence for these results ranges from weak to moderate due to risk of bias, inconsistent results, lack of appropriate statistics and small sample size.

CONCLUSIONS

There appears to be little value in providing PMPR without OHI. In fact, repeated OHI might have a similar effect as PMPR. Some forms of PMPR might achieve greater patient satisfaction. There is little difference in beneficial or adverse effects of different methods of PMPR.

Prevention. Part 7: professionally applied topical fluorides for caries prevention

This paper reviews the use of professionally applied topical fluorides (PATF) in caries prevention. PATFs are indicated for children and adults with one or more decayed smooth surfaces and/or those who are at high caries risk. Frequency of administration depends on the patient's caries risk, and is usually every 6 months. The effectiveness of fluoride varnish and gel applications has been well established in caries prevention trials involving permanent teeth. Although both types are effective, varnish may be preferred because it is easier to apply, reduces the risk of fluoride over-ingestion, and has greater patient acceptance. Fluoride foams are similar products to gels, but have not been tested clinically. The use of in-office two-part rinses is not recommended because they have not been proven effective. A cleaning, or prophylaxis, is not necessary before the application of topical fluoride for caries prevention. In conclusion, when used appropriately, PATFs are a safe, effective means of reducing caries risk among high-risk populations.

Professional topical fluoride applications--clinical efficacy and mechanism of action

All currently used topical fluoride agents deposit soluble fluoride as calcium fluoride on enamel or in lesions. Calcium fluoride serves as a source of fluoride for the formation of fluorapatite. The latter phase is formed when pH drops in plaque, not during topical application. The potential for calcium fluoride formation should probably be increased in topical fluoride agents. In countries with low caries prevalence, the clinical recommendations for topical fluoride need to be reconsidered. Toothpaste is the basic fluoride regimen recommended for everybody. The need for additional fluoride supplementation depends on caries activity. There is no distinct difference in the caries-preventive effects of concentrated fluoride solutions, gels, or varnishes. Thus, the choice of method depends on costs, convenience, patient acceptance, and safety. The use of fluoride varnishes has proven to be a feasible and safe method of fluoride application. With fluoride varnishes, the amounts of fluoride exposure can be better controlled, and less chair-time is required compared with conventional solutions and gels. No dose-response effect to concentrated fluoride agents is apparent, and the benefit of frequent application is not clearly established. In individuals with the most severe cariogenic challenge, combinations of fluoride and antimicrobials may give better clinical effects than fluoride alone.

[Dental caries prevention with semestral topical administration of acidulated phosphate fluoride]

998 children aged 6, 8 and 10, from low income families living in the Federal District, Brazil and attending public, first grade, schools, received bi-annual topical APF Gel-Tray applications. The mass methodology proposed by the National Dental Caries Preventive Program of the Brazilian Ministry of Health, without previous prophylaxis, was adopted. After one year, in fluoridated communities the reduction in the incidence of CPOS was of 31.6%, 24.9% and 39.5%, respectively, for the groups aged 6, 8 and 10. In non fluoridated communities the reductions were, respectively, of 24.3%, 26.6% and 27.7%, in every case with statistic significance at the 95% confidence level. Considering the positive results in a developing area, it is recommended that oral health institutions at all levels could adopt a comprehensive and continuous preventive program for children under their responsibility.

Efficacy of APF treatments without prior toothcleaning targeted to high-risk children

A clinical field trial was conducted, over a 2-yr period, to evaluate the efficacy of bi-annual APF gel topical applications without previous prophylaxis in reducing dental caries among high-risk children living in non-fluoridated communities. 488 children 6 yr old, presenting at least three cavities on proximal surfaces of their primary teeth, were randomly assigned to two groups. The experimental group received bi-annual topical APF gel applications and the control group received a placebo. All treatments were given at school without any prior toothcleaning. The APF gel provided a 34.3% reduction in caries incidence (P-value = 0.03) among the children with 3-14 cavities on their primary teeth at the beginning of the study. However, the treatment did not show any efficacy in reducing caries incidence among the higher-risk children having initially more than 14 cavities. These findings suggest that the efficacy of APF gel applications without previous prophylaxis varies according to the individual risk of the subjects and that more comprehensive programs should be targeted to very high-risk children.

An evaluation of the use of professional (operator-applied) topical fluorides

Application of fluoride solutions, gels, varnishes, and prophylaxis pastes is reviewed as well as the sequential APF/SnF2 office-rinse method. The most widely-used technique is with 1.23% APF gel (12,300 ppm F) in trays. Clinical results from this method are similar to those achieved with an APF solution of the same fluoride concentration. A professional APF gel/tray application need not be preceded by a prophylaxis, should last four min, and should not be followed by a water rinse for 30 min. Fluoride varnishes are newer topical fluoride agents, but their relative efficacy, compared with other proven caries-inhibitory methods, remains to be fully determined. In general, fluoride prophylaxis pastes have not been shown to inhibit caries; however, their use is justified by the ability of some to replenish fluoride lost from the abrasive action of the paste on tooth enamel. The sequential office-rinse method has not been tested in randomized clinical trials, and its use cannot be recommended.

Evaluation of topical fluoride preparations

For practical reasons, evaluation of topical fluoride products must depend upon clinical and laboratory assessments. While not always a good predictor of clinical efficacy by itself, fluoride uptake is the most commonly used laboratory test. A consideration of the relationship between possible anticaries mechanisms of fluoride, different product types, and the meaning of various kinds of fluoride uptake data suggests that both the amount of fluoride taken up by early lesions and the amount of ambient fluoride present at a cariogenic site may play key roles in determining the efficacy of a product. While formulations applied annually or semi-annually probably depend on fluoride deposition, those used daily might not. There are no clear data supporting the superiority of one fluoride compound over another, even for infrequently used products, although there are significant differences among them in fluoride uptake by enamel. This suggests that fluoride uptake in vivo at a cariogenic site might actually be different from that suggested by in vitro data, or that larger differences are required for a clinical effect to be observable. Clinical data support the conclusion that a large increase in the fluoride concentration of a product will somewhat increase its anticaries effectiveness, although the increase will not be linearly related to concentration. There also are no obvious differences in clinical effectiveness caused by the addition of gelling agents to topical solutions. Fluoride varnishes are clinically effective but have not been shown to be superior to topical solutions or gels.(ABSTRACT TRUNCATED AT 250 WORDS)

Review of the anticaries effectiveness of professionally applied and self-applied topical fluoride gels

Of the five types of topical fluoride gel products available in the United States, two have not been clinically tested in randomized double blind clinical trials. For those tested, the averaged results of clinical trials involving schoolchildren in fluoride-deficient communities indicate a caries reduction of approximately 26 percent from either a professional or self-administered program. A similar relative reduction can be expected from programs conducted in fluoridated communities, but the absolute caries inhibition is less. Twice-a-year professional applications are more effective than once-a-year applications, and self-applications using trays are more effective than applying the gel on a toothbrush. For subjects beyond school age, there are few clinical studies of either self-applied or professionally applied gels; however, current epidemiological evidence does not indicate a need for public health caries preventive programs for healthy employed adults. For medically compromised patients, especially those exhibiting rampant caries associated with radiation-induced xerostomia, a variety of topical gel procedures appear to be effective in limiting caries.

Caries incidence and costs of prevention programs

Data on caries increments and costs of prevention programs are presented as background information for participants in the workshop. Estimates of annual caries increments were derived from control groups in clinical trials, epidemiologic studies, and national surveys. Cost data were obtained from dental public health directors, program administrators, fluoridation engineers, and water plant operators in different parts of the US. Caries incidence data are reported for age groups: 5-17 years (fluoridated and nonfluoridated areas), 18-44 years, 45-64 years, and 65 and over. Program costs include direct costs primarily and do not allow for program inefficiencies, nor have they attempted to include social costs. All cost data are expressed in 1988 dollars. Direct program costs are included for community water fluoridation, fluoride supplements, fluoride mouthrinses, school fluoridation, and sealant programs. For professionally and self-applied fluoride programs, only material and salary costs are included because total costs could not be located in the literature nor obtained from program directors. All factors and necessary assumptions included in the cost assessments are described.

Intra-oral retention of fluoride by bovine enamel from amine fluoride toothpaste and 0.4% amine fluoride liquid application

The purpose of this study was to compare in vivo fluoride accumulation in enamel and in enamel lesions from a single topical fluoride application and daily toothbrushing with a fluoride dentifrice. Amine fluoride preparations were used for both products. Intra-oral appliances with bovine enamel specimens were worn by volunteers during a period of seven weeks. After this period, the specimens were analyzed for fluoride uptake and change in demineralization susceptibility. The results demonstrated that lesions had a high fluoride uptake capacity. Fluoride content values increased by 25-30 micrograms/cm2 during a single topical application, as compared with 10-15 micrograms/cm2 during seven weeks of toothbrushing. About half the fluoride acquired as a result of topical treatment was lost during subsequent exposure to the oral fluids when no further fluoride supplementation was given. The uptake of fluoride by sound enamel was comparatively small, regardless of the use of fluoride dentifrice or application. The presence of mature plaque at the time of fluoride application did not affect the amounts of fluoride delivered. Acid susceptibility tests showed that the enamel solubility exhibited a negative correlation with fluoride content of the specimens.