Prevalence and severity of dental fluorosis among students from João Pessoa, PB, Brazil

Risk factors for dental caries in Latin American and Caribbean countries

Identifying the risk factors for dental caries is vital in epidemiology and clinical practices for developing effective preventive strategies, both, at the individual and collective levels. Different causality/determination models have been proposed to understand the development process of dental caries. In the present review, we designed a model inspired by the world-known social determinants models proposed in the 90s and more recently in the 10s, wherein the contextual factors are placed more externally and encompass the individual factors. The contextual factors included those related to the cultural and societal values, as well as the social and health government policies. The individual factors were classified into the following categories: socioeconomic (social class, occupation, income, and education level), demographic characteristics (age, sex, and ethnicity), behavioral factors (non-use of fluoride dentifrice, sugar consumption, poor oral hygiene, and lack of preventive dental care), and biological factors (recent caries experience/active caries lesions, biofilm retentive factors, developmental defects of the enamel, disabilities, saliva amount and quality, cariogenic biofilm). Each of these variables was addressed, while focusing on the current evidence from studies conducted in Latin American and Caribbean countries (LACC). Based on the proposed model, educational aspects were addressed, and individual caries risk assessment and management decisions were proposed; further, implications for public health policies and clinical practice were described. The identification of modifiable risk factors for dental caries should be the basis for multi-strategy actions that consider the diversity of Latin American communities.

Vigilância epidemiológica da fluorose dentária em município de clima tropical com água de abastecimento público fluoretada

Resumo O objetivo deste estudo foi avaliar a prevalência e a severidade de fluorose dentária em escolares de 11 a 14 anos de idade em Teresina (PI) Brasil, município de clima tropical com água de abastecimento público fluoretada. Estudo do tipo observacional transversal no qual foram avaliadas 571 crianças distribuídas nas redes pública e particular de ensino. A coleta de dados foi realizada nas unidades escolares, após recolhimento do Termo de Consentimento Livre e Esclarecido (TCLE) e questionário respondido pelos pais referentes às condições socioeconômicas e demográficas e aos hábitos de higiene bucal. O exame dentário foi realizado por um cirurgião-dentista calibrado. O índice aplicado foi o Thylstrup e Fejerskov (TF). A prevalência de fluorose foi de 77,9%, e apenas 12,5% das crianças acometidas apresentaram TF ≥ 3, grau com comprometimento estético. Os pré-molares foram os dentes mais afetados pela fluorose. Dentre os escolares com maior severidade de fluorose, 98,6% dos pertenciam à classe social mais baixa (>B2), 91,5% nasceram e sempre moraram em Teresina, 94,4% consumiam água de abastecimento fluoretada, 76% usaram dentifrício infantil e 64% as mães relataram que engoliam dentifrício. A prevalência de fluorose foi elevada, mas com baixa severidade, em indivíduos expostos à fluoretação desde o nascimento.

Water fluoridation for the prevention of dental caries

BACKGROUND

Dental caries is a major public health problem in most industrialised countries, affecting 60% to 90% of school children. Community water fluoridation was initiated in the USA in 1945 and is currently practised in about 25 countries around the world; health authorities consider it to be a key strategy for preventing dental caries. Given the continued interest in this topic from health professionals, policy makers and the public, it is important to update and maintain a systematic review that reflects contemporary evidence.

OBJECTIVES

To evaluate the effects of water fluoridation (artificial or natural) on the prevention of dental caries.To evaluate the effects of water fluoridation (artificial or natural) on dental fluorosis.

SEARCH METHODS

We searched the following electronic databases: The Cochrane Oral Health Group's Trials Register (to 19 February 2015); The Cochrane Central Register of Controlled Trials (CENTRAL; Issue 1, 2015); MEDLINE via OVID (1946 to 19 February 2015); EMBASE via OVID (1980 to 19 February 2015); Proquest (to 19 February 2015); Web of Science Conference Proceedings (1990 to 19 February 2015); ZETOC Conference Proceedings (1993 to 19 February 2015). We searched the US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization's WHO International Clinical Trials Registry Platform for ongoing trials. There were no restrictions on language of publication or publication status in the searches of the electronic databases.

SELECTION CRITERIA

For caries data, we included only prospective studies with a concurrent control that compared at least two populations - one receiving fluoridated water and the other non-fluoridated water - with outcome(s) evaluated at at least two points in time. For the assessment of fluorosis, we included any type of study design, with concurrent control, that compared populations exposed to different water fluoride concentrations. We included populations of all ages that received fluoridated water (naturally or artificially fluoridated) or non-fluoridated water.

DATA COLLECTION AND ANALYSIS

We used an adaptation of the Cochrane 'Risk of bias' tool to assess risk of bias in the included studies.We included the following caries indices in the analyses: decayed, missing and filled teeth (dmft (deciduous dentition) and DMFT (permanent dentition)), and proportion caries free in both dentitions. For dmft and DMFT analyses we calculated the difference in mean change scores between the fluoridated and control groups. For the proportion caries free we calculated the difference in the proportion caries free between the fluoridated and control groups.For fluorosis data we calculated the log odds and presented them as probabilities for interpretation.

MAIN RESULTS

A total of 155 studies met the inclusion criteria; 107 studies provided sufficient data for quantitative synthesis.The results from the caries severity data indicate that the initiation of water fluoridation results in reductions in dmft of 1.81 (95% CI 1.31 to 2.31; 9 studies at high risk of bias, 44,268 participants) and in DMFT of 1.16 (95% CI 0.72 to 1.61; 10 studies at high risk of bias, 78,764 participants). This translates to a 35% reduction in dmft and a 26% reduction in DMFT compared to the median control group mean values. There were also increases in the percentage of caries free children of 15% (95% CI 11% to 19%; 10 studies, 39,966 participants) in deciduous dentition and 14% (95% CI 5% to 23%; 8 studies, 53,538 participants) in permanent dentition. The majority of studies (71%) were conducted prior to 1975 and the widespread introduction of the use of fluoride toothpaste.There is insufficient information to determine whether initiation of a water fluoridation programme results in a change in disparities in caries across socioeconomic status (SES) levels.There is insufficient information to determine the effect of stopping water fluoridation programmes on caries levels.No studies that aimed to determine the effectiveness of water fluoridation for preventing caries in adults met the review's inclusion criteria.With regard to dental fluorosis, we estimated that for a fluoride level of 0.7 ppm the percentage of participants with fluorosis of aesthetic concern was approximately 12% (95% CI 8% to 17%; 40 studies, 59,630 participants). This increases to 40% (95% CI 35% to 44%) when considering fluorosis of any level (detected under highly controlled, clinical conditions; 90 studies, 180,530 participants). Over 97% of the studies were at high risk of bias and there was substantial between-study variation.

AUTHORS' CONCLUSIONS

There is very little contemporary evidence, meeting the review's inclusion criteria, that has evaluated the effectiveness of water fluoridation for the prevention of caries.The available data come predominantly from studies conducted prior to 1975, and indicate that water fluoridation is effective at reducing caries levels in both deciduous and permanent dentition in children. Our confidence in the size of the effect estimates is limited by the observational nature of the study designs, the high risk of bias within the studies and, importantly, the applicability of the evidence to current lifestyles. The decision to implement a water fluoridation programme relies upon an understanding of the population's oral health behaviour (e.g. use of fluoride toothpaste), the availability and uptake of other caries prevention strategies, their diet and consumption of tap water and the movement/migration of the population. There is insufficient evidence to determine whether water fluoridation results in a change in disparities in caries levels across SES. We did not identify any evidence, meeting the review's inclusion criteria, to determine the effectiveness of water fluoridation for preventing caries in adults.There is insufficient information to determine the effect on caries levels of stopping water fluoridation programmes.There is a significant association between dental fluorosis (of aesthetic concern or all levels of dental fluorosis) and fluoride level. The evidence is limited due to high risk of bias within the studies and substantial between-study variation.

Impact of dental fluorosis on the quality of life of children and adolescents

INTRODUCTION: Dental fluorosis is a disturbance of high prevalence caused by the ingestion of fluoride ions present mainly in toothpaste. Preventive measures to avoid it are still controversial. Thus, knowing the impact that fluorosis can cause on the population's quality of life it is important for planning public health policies.OBJECTIVE: To evaluate the impact of dental fluorosis on the quality of life of children and adolescents.MATERIAL AND METHOD: We studied 300 subjects aged 8 to 12 years divided into 4 groups: children (8-10 years) and adolescents (10 to 12 years) with and without fluorosis. The diagnosis of fluorosis was performed according to the index Thylstrup and Fejerskov and quality of life was evaluated using Child Perceptions Questionnaire 8-10 and 11-14. The socio-demographic characteristics of the patients were also evaluated. For inclusion in the sample, selected patients should present eight permanent incisors with crowns fully erupted. Patients who had extensive restorations, fractured teeth, other dental enamel defects and who wore braces were excluded.RESULT: Fluorosis was present in 64.7% of the patients analyzed and in most cases (80.3%) was mild or very mild. In children, the average overall score of the questionnaire was 15.9 for the group without fluorosis and 18.3 for the group with fluorosis (p = 0.255). The teenagers' score in the group without fluorosis was 26.1, while the group with fluorosis was 22.7 (p = 0.104).CONCLUSION: Dental fluorosis caused impact on the quality of life of the population analyzed only in the functional domain.

Assessment of groundwater quality in a region of endemic fluorosis in the northeast of Brazil

The aim of this study was to estimate the risk for caries and fluorosis in a desertification area, applying the calcium/fluoride concentration ratio of underground water and the quality of water in a selected geographical region. This study was performed in the municipality of São João do Rio do Peixe, located in the tropical semiarid lands of Brazil. A total of 111 groundwater samples were collected. Fluoride concentration varied from 0.11 to 9.33 mg/L. Thirty percent of all samples analyzed showed values above 1.5 mg/L, while 64 % were above the ideal limit of 0.7 mg/L. Mean calcium concentration was 47.6 mg/L, and 14.4 % of all samples presented values above the WHO acceptable limits. The proportional value of calcium/fluoride in water showed that only 12 % of the samples were suitable for dental caries prevention with minimal risk for dental fluorosis. Mapping of the fluoride distribution indicated that approximately 2,465 people could be affected by dental fluorosis and 1,057 people might be affected by skeletal fluorosis. It can be concluded that, in addition to fluoride, many water parameters were not suitable for the drinking water. Mapping out calcium/fluoride ratio may indicate areas of water suitability for caries control, whereas the fluoride concentration solely can indicate the areas with the risk for fluorosis. This approach can be relevant for health authorities for identifying communities where dental caries or dental fluorosis is prevalent.

Prevalência e severidade de fluorose em escolares do município de São Francisco do Conde-BA, 2010

OBJETIVO: O presente estudo objetivou determinar a prevalência de fluorose em escolares do município de São Francisco do Conde, região metropolitana de Salvador-BA. METODOLOGIA: Todos os escolares do 1º ao 5º ano do Ensino Fundamental, que estudavam em escolas com mais de 150 alunos matriculados, foram selecionados, totalizando 1716 escolares. O índice de Dean foi usado para medir o grau de fluorose, conforme preconizado pela OMS. RESULTADO: Foram examinadas 1474 crianças com idade entre sete e 13 anos, sendo 54,61% do gênero masculino e 55,39% residentes na zona rural. Daqueles casos que apresentaram fluorose (39,80%), 37,02% foram classificados como muito leve, 1,97% leve e 0,81% moderada. Os escolares de dez anos de idade apresentaram maior prevalência de fluorose. Não houve diferença de prevalência entre a zona rural e a urbana. CONCLUSÃO: Em função da baixa prevalência encontrada, a fluorose não constitui um problema de saúde pública no município, mas sim uma questão de vigilância sanitária e epidemiológica.

Therapeutic effect of two fluoride varnishes on white spot lesions: a randomized clinical trial

The aim of this randomized clinical trial study was to evaluate the therapeutic effect of two varnish formulations (G1 = 5% NaF, G2 = 6% NaF + 6% CaF(2)) on the remineralization of white spot lesions (WSL). The sample was composed of 15 (7- to 12-year-old) children with 45 active WSL in anterior permanent teeth. The children were randomly divided into two groups providing 22 lesions for G1 and 23 for G2. The children were submitted to weekly varnish applications 4 times. The WSL were evaluated twice: baseline and on week 4. Maximum lesion dimensions (mesiodistal and incisogingival) were measured in millimeters and classified in four grades of size. WSL were also assessed regarding lesion activity by one calibrated examiner. The Pearson chi-square and Fisher's exact tests were used (P < 0.01). WSL reductions were observed in both varnish groups (Chi-square = 0.15, d.f. = 1, P = 0.90), and with similar magnitude (in mm): 1.19 and 1.29 for G1 and G2, respectively. Thirty-six WSL (15 in G1 and 21 in G2) were classified as inactive on week 4, reaching an overall value of 80%. No difference was observed between G1 and G2 regarding activity scores (Fisher's exact test, p > 0.01). It was concluded that after 4 applications the two varnish formulations tested produced similar clinical effects, indicating the reduction and the control of carious activity in most WSL.

Urinary fluoride excretion in children exposed to fluoride toothpaste and to different water fluoride levels in a tropical area of Brazil

The aim of this study was to evaluate the urinary fluoride excretion of 2- to 7-year-old children exposed to different water fluoride concentrations in the city of Catolé do Rocha, PB, Brazil. Forty-two children were allocated to 3 groups according to the concentration of fluoride in the water: G1 (n=10; 0.5-1.0 ppm F), G2 (n=17; 1.1-1.5 ppm F) and G3 (n= 15; >1.51 ppm F). The study was carried out in two 1-week phases with 1-month interval between the moments of data collection: in the first phase, the children used a fluoride toothpaste (FT) (1,510 ppm F) for 1 week, whereas in the second phase a non-fluoride toothpaste (NFT) was used. The urine was collected in a 24-h period in each week-phase according to Marthaler's protocol. The urinary fluoride excretion data expressed as mean (SD) in µg/24 h were: G1-FT= 452.9 (290.2); G1-NFT= 435.1 (187.0); G2-FT= 451.4 (224.0); G2-NFT= 430.3 (352.5); G3-FT=592.3 (390.5); and G3-NFT=623.6 (408.7). There was no statistically significant difference between the water fluoride groups, and regardless of the week phase (ANOVA, p>0.05). The use of fluoride toothpaste (1,510 ppmF) did not promote an increase in urinary fluoride excretion. There was a trend, though not significant, as to the increase of urine fluoride concentration in relation to fluoride concentrations in the water. The excretion values suggest that some children are under risk to develop dental fluorosis and information about the appropriate use of fluoride is necessary in this area.