Noninferiority of Silver Diamine Fluoride vs Sealants for Reducing Dental Caries Prevalence and Incidence: A Randomized Clinical Trial

Importance

Dental caries is the world's most prevalent noncommunicable disease and a source of health inequity; school dental sealant programs are a common preventive measure. Silver diamine fluoride (SDF) may provide an alternative therapy to prevent and control caries if shown to be noninferior to sealant treatment.

Objective

To determine whether school-based application of SDF is noninferior to dental sealants and atraumatic restorative treatment (ART) in the prevalence of dental caries.

Design, Setting, and Participants

The Silver Diamine Fluoride Versus Therapeutic Sealants for the Arrest and Prevention of Dental Caries in Low-Income Minority Children (CariedAway) study was a pragmatic noninferiority cluster-randomized clinical trial conducted from February 2018 to June 2023 to compare silver diamine fluoride vs therapeutic sealants for the arrest and prevention of dental caries. Children at primary schools in New York, New York, with at least 50% of the student population reporting as Black or Hispanic and at least 80% receiving free or reduced lunch were included. This population was selected as they are at the highest risk of caries in New York. Students were randomized to receive either SDF or sealant with ART; those aged 5 to 13 years were included in the analysis. Treatment was provided at every visit based on need, and the number of visits varied by child. Schools with preexisting oral health programs were excluded, as were children who did not speak English. Of 17 741 students assessed for eligibility, 7418 were randomized, and 4100 completed follow-up and were included in the final analysis.

Interventions

Participants were randomized at the school level to receive either a 38% concentration SDF solution or glass ionomer sealants and ART. Each participant also received fluoride varnish.

Main Outcomes and Measures

Primary study outcomes were the prevalence and incidence of dental caries.

Results

A total of 7418 children (mean [SD] age, 7.58 [1.90] years; 4006 [54.0%] female; 125 [1.7%] Asian, 1246 [16.8%] Black, 3648 [49.2%] Hispanic, 153 [2.1%] White, 114 [1.5%] multiple races or ethnicities, 90 [1.2%] other [unspecified], 2042 [27.5%] unreported) were enrolled and randomized to receive either SDF (n = 3739) or sealants with ART (n = 3679). After initial treatment, 4100 participants (55.0%) completed at least 1 follow-up observation. The overall baseline prevalence of dental caries was approximately 27.2% (95% CI, 25.7-28.6). The odds of decay prevalence decreased longitudinally (odds ratio [OR], 0.79; 95% CI, 0.75-0.83) and SDF was noninferior compared to sealants and ART (OR, 0.94; 95% CI, 0.80-1.11). The crude incidence of dental caries in children treated with SDF was 10.2 per 1000 tooth-years vs 9.8 per 1000 tooth-years in children treated with sealants and ART (rate ratio, 1.05; 95% CI, 0.97-1.12).

Conclusions and Relevance

In this school-based pragmatic randomized clinical trial, application of SDF resulted in nearly identical caries incidence compared to dental sealants and ART and was noninferior in the longitudinal prevalence of caries. These findings suggest that SDF may provide an effective alternative for use in school caries prevention.

Trial Registration

ClinicalTrials.gov Identifier: NCT03442309.

The effectiveness of medical nurses in treating children with silver diamine fluoride in a school-based caries prevention program

BACKGROUND

The sustainability of school-based oral health programs depends on the utilization of effective, efficient treatments and the availability of a trained clinical workforce. The objective of this study was to determine whether registered nurses are comparable to dental hygienists in the application and effectiveness of silver diamine fluoride (SDF) and fluoride varnish (FV) for the prevention of dental caries.

METHODS

CariedAway was a school-based study of SDF and FV versus dental sealants and atraumatic restorations. Within the SDF + FV arm, participants were treated by either a licensed dental hygienist or a registered nurse, both under the supervision of a paediatric dentist. Although initial treatment assignment in CariedAway was randomized, assignment to provider was not. The proportion of children who remained caries free after 2 years was assessed for non-inferiority using two-group proportion tests, adjusting for the clustering effect of schools.

RESULTS

A total of 417 children with no untreated caries at baseline were analysed including 298 treated by hygienists and 119 by nurses. The proportion of children who remained caries free after 2 years was 0.81 and 0.80 for those treated by hygienists and nurses, respectively, for a difference of 0.01 (95% CI = -0.07, 0.098) and within the pre-determined non-inferiority margin.

CONCLUSIONS

Nurses may be effective in treating children with silver diamine fluoride and other fluoride varnishes in school-based oral health programs.

School-based caries prevention and the impact on acute and chronic student absenteeism

BACKGROUND

Poor oral health is significantly associated with absenteeism, contributing to millions of lost school hours per year. The effect of school-based dental programs that address oral health care inequities on student attendance has not yet been explored.

METHODS

CariedAway was a longitudinal, cluster-randomized, noninferiority trial of minimally invasive medicines for caries used in a school-based program. We extracted data on school absenteeism and chronically absent students from publicly available data sets for years before, during, and after program onset (2016-2021). Total absences and the proportion of chronically absent students were modeled using multilevel mixed-effects linear and 2-limit tobit regression, respectively.

RESULTS

In years in which treatment was provided through a school-based caries prevention program, schools recorded approximately 944 fewer absences than in nontreatment years (95% CI, -1,739 to -149). Averaged across all study years, schools receiving either treatment had 1,500 fewer absences than comparator schools, but this was not statistically significant. In contrast, chronic absenteeism was found to significantly decrease in later years of the program (b, -.037; 95% CI, -.062 to -.011). Excluding data for years affected by COVID-19 removed significant associations.

CONCLUSIONS

Although originally designed to obviate access barriers to critical oral health care, early integration of school-based dental programs may positively affect school attendance. However, the observed effects may be due to poor reliability of attendance records resulting from the closing of school facilities in response to COVID-19, and further study is needed.

PRACTICAL IMPLICATIONS

School-based caries prevention may also improve educational outcomes, in addition to providing critical oral health care. This clinical trial was registered at ClinicalTrials.gov. The registration number is NCT03442309.

Effect of Silver Diamine Fluoride on Caries Arrest and Prevention: The CariedAway School-Based Randomized Clinical Trial

IMPORTANCE

Dental caries is the most common global childhood disease. To control caries, the Centers for Disease Control and Prevention recommends school-based caries prevention, and the World Health Organization lists glass ionomer cement and silver diamine fluoride as essential medicines for oral disease.

OBJECTIVE

To determine the noninferiority of silver diamine fluoride with fluoride varnish vs traditional glass ionomer sealants with fluoride varnish after 2 years when provided to children via a school-based health care program.

DESIGN, SETTING, AND PARTICIPANTS

The CariedAway study is an ongoing single-blind, cluster randomized, noninferiority trial conducted between February 1, 2019, and June 1, 2023, among 2998 children in 47 New York City primary schools. Children aged 5 to 13 years of any race and ethnicity were recruited from block-randomized schools. Inclusion criteria for schools were a student population of at least 50% Hispanic or Latino or Latina ethnicity and/or Black race and at least 80% of students receiving free or reduced-cost lunch. Statistical analysis is reported through March 2022.

INTERVENTIONS

Children received a single application of silver diamine fluoride with fluoride varnish or an active comparator of glass ionomer sealants and atraumatic restorations with fluoride varnish.

MAIN OUTCOMES AND MEASURES

Primary outcomes were caries arrest and incidence after a 2-year follow-up, assessed using mixed-effects multilevel models and clustered 2-sample proportion tests. The noninferiority margin was 10%. Intention-to-treat analysis was performed using multiple imputation.

RESULTS

A total of 2998 children (1566 girls [52.2%]; mean [SD] age at baseline, 6.6 [1.2] years; 1397 Hispanic or Latino or Latina children [46.6%]; 874 [29.2%] with untreated dental caries) were recruited and treated from September 16, 2019, to March 12, 2020. Follow-up observations were completed for 1398 children from June 7, 2021, to March 2, 2022. The mean (SE) proportion of children with arrested caries was 0.56 (0.04) after experimental treatment and 0.46 (0.04) after control treatment (difference, -0.11; 95% CI, -0.22 to 0.01). The mean (SE) proportion of patients without new caries was 0.81 (0.02) after experimental treatment and 0.82 (0.02) after control treatment (difference, 0.01; 95% CI, -0.04 to 0.06). Analysis of imputed data for the full sample did not deviate from per-protocol analyses. There were no adverse events.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, silver diamine fluoride with fluoride varnish was noninferior to sealants and atraumatic restorations with fluoride varnish for caries arrest and prevention. Results may support the use of silver diamine fluoride as an arresting and preventive agent in school-based oral health programs.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03442309.

Silver diamine fluoride, atraumatic restorations, and oral health-related quality of life in children aged 5-13 years: results from the CariedAway school-based cluster randomized trial

Objective

Silver diamine fluoride (SDF) is a non-surgical treatment for the arrest and prevention of dental caries that results in irreversible black staining of dental decay. The objective of this study was to evaluate the short-term impact of SDF treatment on oral health-related quality of life (OHRQoL) relative to a standard package of glass ionomer sealants and atraumatic restorative treatment (ART) in children aged 5–13 years.

Methods

CariedAway is a pragmatic, longitudinal, cluster-randomized non-inferiority trial of non-surgical interventions for caries. Secondary study outcomes included OHRQoL and academic performance. Oral health-related quality of life was measured at each study visit using the Child Oral Health Impact Profile. Change in OHRQoL was assessed using linear regression and non-inferiority was determined using t tests.

Results

160 children with an average age of 8.7 years completed quality of life assessments. Untreated decay at baseline (approximately 25%) was associated with significantly worse OHRQoL and treatment in both groups resulted in incremental improvement: children receiving SDF improved their OHRQoL scores from 16.44 (SD = 11.12) to 14.62 (SD = 11.90), and those receiving traditional sealants and atraumatic restorations slightly improved from 16.65 (SD = 10.56) to 16.47 (SD = 11.09). Quality of life in children receiving silver diamine fluoride was non-inferior to those receiving sealants and ART at least 6 months post-treatment (mean difference = 1.85, 95% CI = − 2.10, 5.80), and change in OHRQoL did not depend on the severity of baseline decay.

Conclusions

OHRQoL is related to untreated dental caries, and observed changes following SDF treatment were non-inferior relative to standard preventive therapies.

Comprehensive, School-Based Preventive Dentistry: Program Details and Students' Unmet Dental Needs

BACKGROUND

In this paper, we describe the design, program details, and baseline demographics and oral health of participants in ForsythKids, a regional, comprehensive, school-based mobile caries prevention program.

METHODS

We solicited all Massachusetts elementary schools with greater than 50% of students receiving free or reduced-price meals. Six schools initially elected to participate, ultimately followed by over 50 schools. Interventions were based on systematic reviews and randomized controlled caries prevention trials. Participating students received semiannual dental examinations, followed by comprehensive preventive care. Summary statistics regarding oral health indicators were derived from individual tooth- and surface-level data.

RESULTS

Over a 6-year period, data were collected on 6927 children. The number of students per school ranged from 58 to 681. The overall participation rate was 15%, ranging from 10% to 29%. Overall, 57% of the children were younger than 8 years at baseline. Approximately, 54% of children experienced dental decay on any tooth at baseline; 32% had untreated decay on any tooth, 29% had untreated decay on primary teeth, and 10% untreated decay on permanent teeth.

CONCLUSIONS

Untreated dental decay was double the national average, even in schools within several blocks of community dental clinics. These data demonstrate the need for caries prevention beyond the traditional dental practice.

What is the societal economic cost of poor oral health among older adults in the United States? A scoping review

Objective

To assess the state of the literature in the United States quantifying the societal economic cost of poor oral health among older adults.

Background

Proponents of a Medicare dental benefit have argued that addressing the growing need for dental care among the US older adult population will decrease costs from systemic disease and other economic costs due to oral disease. However, it is unclear what the current economic burden of poor oral health among older adults is in the United States.

Methods

We conducted a scoping review examining the cost of poor oral health among older adults and identified cost components that were included in relevant studies.

Results

Other than oral cancer, no studies were found examining the economic costs of poor oral health among older adults (untreated tooth decay, gum disease, tooth loss and chronic disease/s). Only two studies examining the costs of oral cancer were found, but these studies did not assess the full economic cost of oral cancer from patient, insurer and societal perspectives.

Conclusions

Future work is needed to assess the full economic burden of poor oral health among older adults in the United States, and should leverage novel linkages between medical claims data, dental claims data and oral health outcomes data.

Presenting or Spinning Facts? Deconstructing the U.S. Centers for Disease Control Statement on the Importance of Reopening Schools Under COVID-19

Credible, reliable and consistent information to the public, as well as health professionals and decision makers, is crucial to help navigate uncertainty and risk in times of crisis and concern. Traditionally, information and health communications issued by respected and established government agencies have been regarded as factual, unbiased and credible. The U.S. Centers for Disease Control and Prevention (CDC) is such an agency that addresses all aspects of health and public health on behalf of the U.S Government for the benefit of its citizens. In July 2020, the CDC issued guidelines on reopening schools which resulted in open criticism by the U.S. President and others, prompting a review and publication of revised guidelines together with a special "Statement on the Importance of Reopening Schools under COVID-19." We hypothesize that this statement introduced bias with the intention to shift the public perception and media narrative in favor of reopening of schools. Using a mixed methods approach, including an online text analysis tool, we demonstrate that document title and structure, word frequencies, word choice, and website presentation did not provide a balanced account of the complexity and uncertainty surrounding school reopening during the COVID-19 pandemic. Despite available scientific guidance and practical evidence-based advice on how to manage infection risks when reopening schools, the CDC Statement was intentionally overriding possible parent and public health concerns. The CDC Statement provides an example of how political influence is exercised over the presentation of science in the context of a major pandemic. It was withdrawn by the CDC in November 2020.

Longitudinal caries prevalence in a comprehensive, multicomponent, school-based prevention program

BACKGROUND

Globally, children's caries prevalence exceeds 30% and has not markedly changed in 30 years. School-based caries prevention programs can be an effective method to reduce caries prevalence, obviate traditional barriers to care, and use aerosol-free interventions. The objective of this study was to explore the clinical effectiveness of a comprehensive school-based, aerosol-free, caries prevention program.

METHODS

The authors conducted a 6-year prospective open cohort study in 33 US public elementary schools, providing care to 6,927 children in communities with and without water fluoridation. After dental examinations, dental hygienists provided twice-yearly prophylaxis, glass ionomer sealants, glass ionomer interim therapeutic restorations, fluoride varnish, toothbrushes, fluoride toothpaste, oral hygiene instruction, and referral to community dentists as needed. The authors used generalized estimating equations to estimate the change in the prevalence of untreated caries over time.

RESULTS

The prevalence of untreated caries decreased by more than 50%: from 39% through 18% in phase 1, and from 28% through 10% in phase 2. The per-visit adjusted odds ratio of untreated caries was 0.79 (95% confidence interval, 0.73 to 0.85).

CONCLUSIONS AND PRACTICAL IMPLICATIONS

This school-based comprehensive caries prevention program was associated with substantial reductions in children's untreated caries, supporting the concept of expanding traditional practices to include office- and community-based aerosol-free care.

Pandemic Considerations on Essential Oral Health Care

The coronavirus disease 2019 (COVID-19) pandemic revealed a lack of consensus on the concept of essential oral health care. We propose a definition of essential oral health care that includes urgent and basic oral health care to initiate a broader debate and stakeholder alignment. We argue that oral health care must be part of essential health care provided by any health system. Essential oral health care covers the most prevalent oral health problems through an agreed-on set of safe, quality, and cost-effective interventions at the individual and community level to promote and protect oral health, as well as prevent and treat common oral diseases, including appropriate rehabilitative services, thereby maintaining health, productivity, and quality of life. By default, essential oral health care does not include the full spectrum of possible interventions that contemporary dentistry can provide. On the basis of this definition, we conceptualize a layered model of essential oral health care that integrates urgent and basic oral health care, as well as advanced/specialist oral health care. Finally, we present 3 key reflections on the essentiality of oral health care. First, oral health care must be an integral component of a health care system's essential services, and by implication, oral health care personnel are part of the essential health care workforce. Second, not all dental care is essential oral health care, and not all essential care is also urgent, particularly under the specific risk conditions of the pandemic. Third, there is a need for criteria, evidence, and consensus-building processes to define which dental interventions are to be included in which category of essential oral health care. All stakeholders, including the research, academic, and clinical communities, as well as professional organizations and civil society, need to tackle this aspect in a concerted effort. Such consensus will be crucial for dentistry in view of the Sustainable Development Goal's push for universal health coverage, which must cover essential oral health care.

Systemic Management of Pandemic Risks in Dental Practice: A Consolidated Framework for COVID-19 Control in Dentistry

Dental teams and their workplaces are among the most exposed to airborne and bloodborne infectious agents, and therefore at the forefront of pandemic-related changes to how dental care is organized and provided to patients. The increasing complexity of guidelines makes is challenging for clinicians to navigate the multitude of COVID-19 guidelines issued by different agencies. A comparative analysis of guidance issued for managing COVID-19 in dental settings leading U.S. agencies was conducted, including documents of the Occupational Safety and Health Administration (OSHA), an agency of the U.S. Secretary of Labor, and of the U.S. Centers for Disease Prevention and Control (CDC), an agency of the U.S. Secretary of Health and Human Services. Details of infection control and other risk mitigation measures were reviewed for consistency, overlaps and similarities, then clustered according to thematic areas covering all domains of managing a dental healthcare setting. The analysis revealed five distinct areas of pandemic control, comprising (1) planning and protocols, (2) patient screening, (3) preparation of facilities, (4) PPE and infection control, and (5) procedures and aerosol control; thereby covering systematically all aspects requiring adaptation in a pandemic context. The "Pandemic-5 Framework for COVID-19 Control in Dentistry" provides an opportunity to simplify comprehensive decision-making from a clinical practitioner perspective. The framework supports a comprehensive systems-driven approach by using dental clinics as a setting to integrate pandemic clinical responses with the implementation of appropriate infection control protocols. Traditionally these two aspects are addressed independently from each other in separate concepts.

Developing a Standard Set of Patient-centred Outcomes for Adult Oral Health - An International, Cross-disciplinary Consensus

Objective

To develop a minimum Adult Oral Health Standard Set (AOHSS) for use in clinical practice, research, advocacy and population health.

Materials and methods

An international oral health working group (OHWG) was established, of patient advocates, researchers, clinicians and public health experts to develop an AOHSS. PubMed was searched for oral health clinical and patient-reported measures and case-mix variables related to caries and periodontal disease. The selected patient-reported outcome measures focused on general oral health, and oral health-related quality of life tools. A consensus was reached via Delphi with parallel consultation of subject matter content experts. Finally, comments and input were elicited from oral health stakeholders globally, including patients/consumers.

Results

The literature search yielded 1,453 results. After inclusion/exclusion criteria, 959 abstracts generated potential outcomes and case-mix variables. Delphi rounds resulted in a consensus-based selection of 80 individual items capturing 31 outcome and case-mix concepts. Global reviews generated 347 responses from 87 countries, and the patient/consumer validation survey elicited 129 responses. This AOHSS includes 25 items directed towards patients (including demographics, the impact of their oral health on oral function, a record of pain and oral hygiene practices, and financial implications of care) and items for clinicians to complete, including medical history, a record of caries and periodontal disease activity, and types of dental treatment delivered.

Conclusion

In conclusion, utilising a robust methodology, a standardised core set of oral health outcome measures for adults, with a particular emphasis on caries and periodontal disease, was developed.

Nuclear F-actin Cytology in Oral Epithelial Dysplasia and Oral Squamous Cell Carcinoma

Oral cavity cancer has a low 5-y survival rate, but outcomes improve when the disease is detected early. Cytology is a less invasive method to assess oral potentially malignant disorders relative to the gold-standard scalpel biopsy and histopathology. In this report, we aimed to determine the utility of cytological signatures, including nuclear F-actin cell phenotypes, for classifying the entire spectrum of oral epithelial dysplasia and oral squamous cell carcinoma. We enrolled subjects with oral potentially malignant disorders, subjects with previously diagnosed malignant lesions, and healthy volunteers without lesions and obtained brush cytology specimens and matched scalpel biopsies from 486 subjects. Histopathological assessment of the scalpel biopsy specimens classified lesions into 6 categories. Brush cytology specimens were analyzed by machine learning classifiers trained to identify relevant cytological features. Multimodal diagnostic models were developed using cytology results, lesion characteristics, and risk factors. Squamous cells with nuclear F-actin staining were associated with early disease (i.e., lower proportions in benign lesions than in more severe lesions), whereas small round parabasal-like cells and leukocytes were associated with late disease (i.e., higher proportions in severe dysplasia and carcinoma than in less severe lesions). Lesions with the impression of oral lichen planus were unlikely to be either dysplastic or malignant. Cytological features substantially improved upon lesion appearance and risk factors in predicting squamous cell carcinoma. Diagnostic models accurately discriminated early and late disease with AUCs (95% CI) of 0.82 (0.77 to 0.87) and 0.93 (0.88 to 0.97), respectively. The cytological features identified here have the potential to improve screening and surveillance of the entire spectrum of oral potentially malignant disorders in multiple care settings.

A Dental Response to the COVID-19 Pandemic-Safer Aerosol-Free Emergent (SAFER) Dentistry

Dental services are significantly impacted by the COVID-19 pandemic. Almost all dental procedures carry a high infection risk for providers and patients due to the spread of aerosols. As a consequence, public health agencies and professional associations have issued guidelines for enhanced infection control and personal protection equipment and have also limited care to urgent or emergency services. However, there is no dental service concept for pandemic disaster preparedness or response that might be applied. Moreover, pathways to dental care provision in a post-pandemic future with persisting risks are needed. We propose Safer Aerosol-Free Emergent Dentistry (SAFER Dentistry) as one approach to dental services during and emerging from the pandemic. The concept's starting point is the identification of the most common patient needs. The next step is to replace common treatments addressing the most frequent needs with alternative interventions involving a lower infection risk because they do not generate aerosols. SAFER Dentistry is innovative, avoids risk, and responds to the requirements of a pandemic and post-pandemic emergency where the risk of airborne disease transmission remains high. SAFER Dentistry thereby ensures continuity of dental services while protecting providers and patients from infectious pathogens. Moreover, SAFER Dentistry allows dental service providers to remain operational and generate income even under pandemic conditions. Potential implementation and policy options for SAFER Dentistry include universal availability without co-payments by patients and a uniform bundled payment scheme for providers to simplify budgeting, reimbursement, and administration during a pandemic. Adaptations and adjustments of the concept are possible and encouraged as long as the principle of avoiding aerosol-generating procedures is maintained.

Periodontal disease as a possible cause for Alzheimer's disease

Approximately 47 million people worldwide have been diagnosed with dementia, 60%-80% of whom have dementia of the Alzheimer's disease type. Unfortunately, there is no cure in sight. Defining modifiable risk factors for Alzheimer's disease may have a significant impact on its prevalence. An increasing body of evidence suggests that chronic inflammation and microbial dysbiosis are risk factors for Alzheimer's disease. Periodontal disease is a chronic inflammatory disease that develops in response to response to microbial dysbiosis. Many studies have shown an association between periodontal disease and Alzheimer's disease. The intent of this paper was to review the existing literature and determine, using the Bradford Hill criteria, whether periodontal disease is causally related to Alzheimer's disease.

School-based caries prevention and longitudinal trends in untreated decay: an updated analysis with Markov chains

OBJECTIVE

Dental caries (tooth decay) is the most prevalent childhood disease in the world. A school-based program for the prevention of dental caries providing bi-annual sealants, interim therapeutic restorations, and fluoride varnish to children aged 5-12 years was previously associated with a significant reduction in the prevalence of untreated tooth decay over time. The objective of this study was to explore potential nonlinear change in the risk of untreated decay in children receiving caries prevention.

RESULTS

Across all study participants, there was a significant increase in the odds of untreated tooth decay over time (OR = 1.90, 95% CI 1.51, 2.39), but the rate of this risk rapidly decreased with each observational visit (OR = 0.87, 95% CI 0.93, 0.91). Overall effects substantially depended on the oral health status of participants at baseline: for children with untreated decay at their first observation, the odds of untreated decay over time was 0.39 (95% CI 0.27, 0.55). A quadratic change for this subpopulation showed that the per-visit decrease in decay was attenuated with each subsequent observation (OR = 1.12, 95% CI 1.04, 1.20).

Quality Appraisal of Child Oral Health-Related Quality of Life Measures: A Scoping Review

BACKGROUND

Children's oral health-related quality of life (COHQoL) measures are well known and widely used. However, rigorous systematic reviews of these measures and analyses of their quality are in absence.

OBJECTIVES

To systematically review and quantitatively assess the quality of COHQoL measures through a scoping review.

DATA SOURCES

Systematic literature search of PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), EMBASE (Excerpta Medica database), HaPI (Health and Psychosocial Instruments), and DOSS (Dentistry and Oral Sciences Source).

STUDY ELIGIBILITY

The measure's focus was COHQoL; the child age ranged from 5 to 14 years; the publication was either a research article or a systematic review and related to caries; and it was written in English or had an English abstract. Two authors independently selected the studies. Disagreements were reconciled by group discussions with a third author.

APPRAISAL

The International Society for Quality of Life Research minimum standards for patient-reported outcome measures were used for quality appraisal.

SYNTHESIS

Descriptive analysis.

RESULTS

We identified 18 measures. Their quality scores ranged from 9.5 to 15.0 on a scale of 16. The quality appeared to bear no relationship to the citation and use of these measures. However, elements of these measures might be more useful than others, depending on the age-specific use and primary quality concerns.

LIMITATIONS

Some of the information on the minimum standards of the 18 measures cannot be found in the existing literature. Measures published without English abstract were not searched.

CONCLUSIONS

The quality of these measures is suboptimal. Researchers and practitioners in this field should exercise caution when choosing and using these measures. Efforts at improving the quality of the COHQoL measures, such as refining existing ones or developing new measures, are warranted.

KNOWLEDGE TRANSFER STATEMENT

Researchers, clinician scientists, and clinicians can use the results of this study when deciding which oral health-related quality of life measure they wish to use in children.

An Economic Evaluation of a Comprehensive School-Based Caries Prevention Program

INTRODUCTION

Current economic evaluations of school-based caries prevention programs (SCPPs) do not compare multiple types of SCPPs against each other and do not consider teeth beyond permanent first molars.

OBJECTIVES

To assess the cost-effectiveness of a comprehensive SCPP relative to an SCPP focused on delivering sealants for permanent first molars only and to a default of no SCPP. Based on a societal perspective, a simulation model was used that compared the health and cost impacts on 1) permanent first molars only and 2) all posterior teeth.

METHODS

To calibrate the model, we used data from CariedAway, a comprehensive SCPP that used glass ionomer to prevent and arrest active decay among children. We then evaluated the incremental cost-effectiveness of implementing 3 alternate school-based approaches (comprehensive, sealant only, and no program) on only first molars and all posterior teeth. Probabilistic, 1-, and 2-way sensitivity analyses are included for robustness. Cost-effectiveness is assessed with a threshold of $54,639 per averted disability-adjusted life year (DALY).

RESULTS

We first compared the 3 programs under the assumption of treating only first molars. This assessment indicated that CariedAway was less cost-effective than school-based sealant programs (SSPs): the resulting incremental cost-effectiveness ratio (ICER) for CariedAway versus SSPs was $283,455 per averted DALY. However, when the model was extended to include CariedAway's treatment of all posterior teeth, CariedAway was not only cost-effective but also cost-saving relative to SSPs (ICER, -$943,460.88 per averted DALY; net cost, -$261.45) and no SCPP (ICER, -$400,645.52 per averted DALY; net cost, -$239.77).

CONCLUSIONS

This study finds that economic evaluations assessing only cost and health impacts on permanent first molars may underestimate the cost-effectiveness of comprehensive SCPPs 1) preventing and arresting decay and 2) treating all teeth. Hence, there is an urgent need for economic evaluations of SCPPs to assess cost and health impacts across teeth beyond only permanent first molars.

KNOWLEDGE TRANSFER STATEMENT

The results of this study can be used by policy makers to understand how to evaluate economic evaluations of school-based caries prevention programs and what factors to consider when deciding on what types of programs to implement.

Evidence-Based Dentistry Update on Silver Diamine Fluoride

This article reviews current evidence on the effectiveness of silver diamine fluoride (SDF) as a caries arresting and preventive agent. It provides clinical recommendations around SDF's appropriate use as part of a comprehensive caries management program. Systematic reviews confirm that SDF is effective for caries arrest on cavitated lesions in primary teeth and root caries in the elderly. It may also prevent new lesions. Application is easy, noninvasive, affordable, and safe. Although it stains the lesions dark as it arrests them, it provides clinicians with an additional tool for caries management when esthetics are not a primary concern.

Silver diamine fluoride versus therapeutic sealants for the arrest and prevention of dental caries in low-income minority children: study protocol for a cluster randomized controlled trial

BACKGROUND

Dental caries is the most prominent childhood disease in the world. In the United States, more than 50% of children have experienced caries. Untreated caries can have negative impacts on quality of life, academic performance, and school attendance. To reduce oral health disparities, multiple organizations recommend school-based caries prevention.

METHODS/DESIGN

A longitudinal, cluster randomized, non-inferiority trial will be conducted in low-income children from primarily Hispanic/Latino backgrounds currently enrolled in public elementary schools in New York City, New York, United States, from 2018 to 2023. The primary objective is to compare the non-inferiority of silver diamine fluoride and fluoride varnish versus glass ionomer therapeutic sealants and fluoride varnish in the arrest and prevention of dental caries. Secondary objectives are to evaluate differences in effectiveness when care is provided by nurses versus dental hygienists and assess the impact of prevention on oral health-related quality of life and educational outcomes. Caries arrest will be evaluated after 2 years, and caries prevention and secondary outcomes will be assessed at the completion of the study. Data analysis will follow intent-to-treat, and statistical analyses will be conducted using a two-sided significance level of 0.05.

DISCUSSION

The comparative effectiveness of alternative caries prevention delivery models is considered to be one of the highest research priorities in the United States. Many treatments are currently available to prevent and arrest dental caries. The simplicity and affordability of silver diamine fluoride may be a viable alternative for the prevention of dental caries in high-risk children.

TRIAL REGISTRATION

U.S. National Library of Medicine, www.clinicaltrials.gov , ID: NCT03442309 . Registered on 22 February 2018.

Controlling caries in exposed root surfaces with silver diamine fluoride: A systematic review with meta-analysis

BACKGROUND

In this systematic review, the authors aim to assess the effect of silver diamine fluoride (SDF) in preventing and arresting caries in exposed root surfaces of adults.

TYPES OF STUDIES REVIEWED

Two reviewers independently searched for controlled clinical trials with at least 12 months of follow-up, without language or date of publication restraints, in 8 electronic databases, 5 registries of ongoing trials, and reference lists of narrative reviews.

RESULTS

The authors found 2,356 unique records and included 3 trials in which the investigators randomly assigned 895 older adults. Investigators in all studies compared SDF with placebo; investigators in 1 also compared 38% SDF with chlorhexidine and sodium fluoride varnishes. The primary effect measures were the weighted mean differences (WMDs) in decayed or filled root surfaces (DFRS) and the mean differences in arrested carious lesions between SDF and control groups. The studies had low risk of bias in most domains. SDF applications had a significantly better preventive effect in comparison with placebo (WMD DFRS: 24 months, -0.56; 95% confidence interval, -0.77 to -0.36; 30 months or more, -0.80; 95% confidence interval, -1.19 to -0.42), and they were as effective as either chlorhexidine or sodium fluoride varnish in preventing new root carious lesions. SDF also provided a significantly higher caries arrest effect than did placebo (pooled results not calculated). Complaints about black staining of the carious lesions by SDF were rare among older adults.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Yearly 38% SDF applications to exposed root surfaces of older adults are a simple, inexpensive, and effective way of preventing caries initiation and progression.

The Effect of Silver Diamine Fluoride in Preventing Caries in the Primary Dentition: A Systematic Review and Meta-Analysis

OBJECTIVES

To investigate whether silver diamine fluoride (SDF) is effective in preventing new caries lesions in primary teeth when compared to placebo or active treatments.

METHODS

Systematic review (CRD42016036963) of controlled clinical trials. Searches were performed in 9 electronic databases, 5 registers of ongoing trials, and reference lists of identified review articles. Two researchers carried out data extraction and quality appraisal independently. The primary outcome was the difference in caries increment (decayed, missing, and filled surfaces or teeth - dmfs or dmft) between SDF and control groups. These differences were pooled as weighted mean differences (WMD) and prevented fractions (PF).

RESULTS

Searches yielded 2,366 unique records; 6 reports of 4 trials that randomized 1,118 and analyzed 915 participants were included. Two trials compared SDF to no treatment, 1 compared SDF to placebo and sodium fluoride varnish (FV), and 1 compared SDF to high-viscosity glass ionomer cement (GIC). All studies had at least 1 domain with unclear or high risk of bias. After 24 months of follow-up, in comparison to placebo, no treatment, and FV, SDF applications significantly reduced the development of new dentin caries lesions (placebo or no treatment: WMD = -1.15, PF = 77.5%; FV: WMD = -0.43, PF = 54.0%). GIC was more effective than SDF after 12 months of follow-up but the difference between them was not statistically significant (WMD, dmft: 0.34, PF: -6.09%).

CONCLUSION

When applied to caries lesions in primary teeth, SDF compared to no treatment, placebo or FV appears to effectively prevent dental caries in the entire dentition. However, trials specifically designed to assess this outcome are needed.

Comparative effectiveness of treatments to prevent dental caries given to rural children in school-based settings: protocol for a cluster randomised controlled trial

INTRODUCTION

Dental caries is the most prevalent childhood disease in the world and can lead to infection, pain and reduced quality of life. Multiple prevention agents are available to arrest and prevent dental caries; however, little is known of the comparative effectiveness of combined treatments when applied in pragmatic settings. The aim of the presented study is to compare the benefit of silver diamine fluoride and fluoride varnish versus fluoride varnish and glass ionomer therapeutic sealants in the arrest and prevention of dental caries.

METHODS AND ANALYSIS

A longitudinal, pragmatic, cluster randomised, single-blind, non-inferiority trial will be conducted in low-income rural children enrolled in public elementary schools in New Hampshire, USA, from 2018 to 2023. The primary objective is to compare the non-inferiority of alternative agents in the arrest and prevention of dental caries. The secondary objective is to compare cost-effectiveness of both interventions. Caries arrest will be evaluated after 2 years, and caries prevention will be assessed at the completion of the study. Data analysis will follow intent to treat, and statistical analyses will be conducted using a significance level of 0.05.

ETHICS AND DISSEMINATION

The standard of care for dental caries is office-based surgery, which presents multiple barriers to care including cost, fear and geographic isolation. The common intervention used in school-based caries prevention is dental sealants. The simplicity and affordability of silver diamine fluoride may be a viable alternative for the prevention of dental caries in high-risk children. Results can be used to inform policy for best practices in school-based oral healthcare.

TRIAL REGISTRATION

NCT03448107. Pre-results.

Comparative effectiveness of school-based caries prevention: a prospective cohort study

Background

Dental caries is the world’s most prevalent childhood disease. School-based caries prevention can reduce the risk of childhood caries by increasing access to care. However, the optimal mix of treatment services, intensity, and frequency of care is unknown.

Methods

Data were derived from two prospective cohorts of US children participating in two caries prevention programs with different treatment intensities. One program provided primary and secondary prevention (glass ionomer sealants and interim therapeutic restorations) and one primary prevention only (glass ionomer sealants), both given twice yearly in six-month intervals. Primary study outcomes included untreated decay and the total observed caries experience. Analysis used generalized additive models to estimate nonlinear effects and trends over time. Results were compared to those estimated using generalized estimating equations and mixed-effects multilevel Poisson regression.

Results

Primary and secondary prevention combined did not significantly reduce total caries experience compared to primary prevention alone, but did reduce the risk of untreated decay on permanent dentition. Additionally, the rate of new caries experience was slower in the primary and secondary prevention group. Nonlinear trends for dental caries across both programs were statistically significant from zero (p < .001).

Conclusion

Caries prevention consisting of primary and secondary prevention agents may be more effective than primary prevention alone in reducing the risk of tooth decay over time. Results suggest that the impact of caries prevention may not be constant over the medium- and long-term, suggesting reduced effectiveness with continued treatments.

School-Based Caries Prevention, Tooth Decay, and the Community Environment

The school and community context can contribute to inequity in child oral health. Whether the school and community affect the effectiveness of school-based caries prevention is unknown. The association between the school and community environment and dental caries, as well as their moderating effects with school-based caries prevention, was assessed using multilevel mixed-effects regression. Data were derived from a 6-y prospective cohort study of children participating in a school-based caries prevention program. For the school and community, living in a dental-shortage area and the proportion of children receiving free or reduced lunch were significantly related to an increased risk of dental caries at baseline. Caries prevention was associated with a significant per-visit decrease in the risk of untreated caries, but the rate of total caries experience increased over time. Caries prevention was more effective in children who had prior dental care at baseline and in schools with a higher proportion of low socioeconomic status students. There was significant variation across schools in the baseline prevalence of dental caries and the effect of prevention over time, although effects were modest. The school and community environment have a direct impact on oral health and moderate the association between school-based caries prevention and dental caries. Knowledge Transfer Statement: School-based caries prevention can be an effective means to reduce oral health inequity by embedding dental care within schools. However, the socioeconomic makeup of schools and characteristics of the surrounding community can affect the impact of school-based care.

Preventable Tooth Loss in Hawai'i: The Role of Socioeconomic Status, Diabetes, and Dental Visits

Introduction

Tooth preservation in adults and children is one of the Healthy People 2020 goals for oral health. Although the overall prevalence of tooth loss has been declining in the United States, substantial racial/ethnic differences in preventable tooth loss persist as a public health problem. We examined the strength of the association of health risk factors and tooth loss in Hawai‘i.

Methods

We used data from the Hawai‘i Behavioral Risk Factor Surveillance System survey collected from 2011 through 2014. Participant responses were included if they self-identified as Native Hawaiian, white, Japanese, or Filipino. Differences in excess tooth loss (6 or more teeth) and known risk factors (demographics, diabetes, and dental visits) were analyzed by using univariate analyses and adjusted stepwise, logistic regression models.

Results

We identified oral health inequity among the 4 ethnic groups studied; among the groups, Native Hawaiians had the largest proportion of excess tooth loss. The univariate analyses found differences in the strength of these associations among the 4 racial/ethnic groups. The stepwise analyses found that the associations of excess tooth loss and race/ethnicity were not significant after adjusting for demographics, diabetes status, and dental visits.

Conclusion

Findings suggest a need for programs and policies that improve access to oral health care in Hawai‘i for those with low levels of income and education and those with diabetes.

Getting the Incentives Right: Improving Oral Health Equity With Universal School-Based Caries Prevention

Despite significant financial, training, and program investments, US children's caries experience and inequities continued to increase over the last 20 years. We posit that (1) dental insurance payment systems are not aligned with the current best evidence, exacerbating inequities, and (2) system redesign could meet health care's triple aim and reduce children's caries by 80%. On the basis of 2013 to 2016 Medicaid and private payment rates and the caries prevention literature, we find that effective preventive interventions are either (1) consistently compensated less than ineffective interventions or (2) not compensated at all. This economic and clinical misalignment may account for underuse of effective caries prevention and subsequent overuse of restorative care. We propose universal school-based comprehensive caries prevention to address this misalignment. Preliminary modeling suggests that universal caries prevention could eliminate 80% of children's caries and cost less than one fifth of current Medicaid children's oral health spending. If implemented with bundled payments based on cycle of care and measurable outcomes, there would be an alignment of incentives, best evidence, care, and outcomes. Such a program would meet the Healthy People Oral Health goals for children, as well as health care's triple aim.

Parental perceptions and acceptance of silver diamine fluoride staining

BACKGROUND

The caries arrest that can be achieved by using silver diamine fluoride (SDF) offers a minimally invasive and inexpensive alternative to traditional restorative caries treatment. The authors evaluated how the dentinal staining that is associated with SDF influences the acceptance of this treatment among parents of young children in the New York City metropolitan area.

METHODS

The authors invited the parents of children who had experienced dental caries and who had appointments at the New York University Pediatric Dentistry Clinic and at several private clinics in New Jersey to participate in a Web-based survey designed to assess parents' demographics, perceptions of photographs of SDF-treated carious teeth, and acceptability of treatment in different behavior management scenarios.

RESULTS

Ninety-eight mothers and 22 fathers from diverse backgrounds participated. Most parents (67.5%) judged SDF staining on the posterior teeth to be esthetically tolerable, but only 29.7% of parents made this same judgment about anterior teeth (P < .001). In the absence of their child having behavioral barriers to conventional restorations, 53.6% of parents reported that they were likely to choose SDF to treat their child's posterior teeth, but only 26.9% of parents were likely to choose SDF to treat their child's anterior teeth. As the number of children's behavioral barriers increased, so did the parents' level of acceptance. In extreme cases, in which parents had to decide whether their children should undergo general anesthesia during treatment, parents' acceptance rate of SDF as a treatment method increased to 68.5% on posterior teeth and to 60.3% on anterior teeth. Parents' acceptance of the treatment also varied according to their socioeconomic status.

CONCLUSIONS

Staining on posterior teeth was more acceptable than staining on anterior teeth. Although staining on anterior teeth was undesirable, most parents preferred this option to advanced behavioral techniques such as sedation or general anesthesia.

PRACTICAL IMPLICATIONS

Clinicians need to understand parental sensitivities regarding the staining effect of SDF to plan adequately for the use of SDF as a method of caries management in pediatric patients.

Oral Epithelial Overexpression of IL-1α Causes Periodontal Disease

Periodontal disease is a bacterial infection that results in inflammatory destruction of tissues that support the teeth, including connective tissue and bone. In this study, we report that transgenic mice that overexpress the 17-kDa form of IL-1α in the basal layer of oral mucosal epithelium develop a syndrome that possesses all of the cardinal features of periodontal disease, including epithelial proliferation and apical migration, loss of attachment, and destruction of cementum and alveolar bone. In this model, bacterial colonization and infection were not required, since levels of periodontal bacteria were equivalent in transgenic and wild-type mice, and continuous treatment with antibiotics from birth did not ameliorate the disease. Our findings therefore indicate that elevated levels of IL-1α in the oral micro-environment can mediate all of the clinical features of periodontal disease.

Silver Diamine Fluoride Treatment Considerations in Children's Caries Management

By arresting and preventing caries, silver diamine fluoride (SDF) offers an alternate care path for patients for whom traditional restorative treatment is not immediately available. Current data from controlled clinical trials encompassing more than 3,900 children indicate that biannual application of SDF reduces progression of current caries and risk of subsequent caries. The purpose of this paper was to highlight the best evidence from systematic reviews and clinical trials for clinicians to consider the benefits, risks, and limitations as they implement silver diamine fluoride therapy on young children.

EVIDENCE BASED DENTISTRY AND CODA REQUIREMENTS

Most of us assume that what we do, and teach, is evidence-based. The challenge is to insure that this is indeed the case. More to the point, how can we readily find the credible evidence we need to guide practice and teaching? And, can we differentiate high-quality evidence from less trustworthy reports? This paper presents a basic, three-step process for querying the literature, identifying levels of evidence, evaluating the evidence, and summarizes the early experiences of three dental schools in developing a curriculum that incorporates EBD and critical thinking.

Moderate quality evidence finds statistical benefit in oral health for powered over manual toothbrushes

DATA SOURCES

The Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, CINAHL, National Institutes of Health Trials Register and the WHO Clinical Trials Registry Platform for ongoing trials. Reference lists of identified articles were also scanned for relevant papers. Identified manufacturers were contacted for additional information.

STUDY SELECTION

Only randomised controlled trials comparing manual and powered toothbrushes were considered. Crossover trials were eligible for inclusion if the wash-out period length was more than two weeks.

DATA EXTRACTION AND SYNTHESIS

Study assessment and data extraction were carried out independently by at least two reviewers. The primary outcome measures were quantified levels of plaque or gingivitis. Risk of bias assessment was undertaken. Standard Cochrane methodological approaches were taken. Random-effects models were used provided there were four or more studies included in the meta-analysis, otherwise fixed-effect models were used. Data were classed as short term (one to three months) and long term (greater than three months).

RESULTS

Fifty-six trials were included with 51 (4624 patients) providing data for meta-analysis. The majority (46) were at unclear risk of bias, five at high risk of bias and five at low risk. There was moderate quality evidence that powered toothbrushes provide a statistically significant benefit compared with manual toothbrushes with regard to the reduction of plaque in both the short and long-term. This corresponds to an 11% reduction in plaque for the Quigley Hein index (Turesky) in the short term and a 21% reduction in the long term. There was a high degree of heterogeneity that was not explained by the different powered toothbrush type subgroups.There was also moderate quality evidence that powered toothbrushes again provide a statistically significant reduction in gingivitis when compared with manual toothbrushes both in the short and long term. This corresponds to a 6% and 11% reduction in gingivitis for the Löe and Silness indices respectively. Again there was a high degree of heterogeneity that was not explained by the different powered toothbrush type subgroups. The greatest body of evidence was for rotation oscillation brushes which demonstrated a statistically significant reduction in plaque and gingivitis at both time points.

CONCLUSIONS

Powered toothbrushes reduce plaque and gingivitis more than manual toothbrushing in the short and long term. The clinical importance of these findings remains unclear. Observation of methodological guidelines and greater standardisation of design would benefit both future trials and meta-analyses. Cost, reliability and side effects were inconsistently reported. Any reported side effects were localised and only temporary.

Obesity and dental decay: inference on the role of dietary sugar

OBJECTIVE

To evaluate the relationship of children's obesity and dental decay.

METHODS

We measured parameters related to obesity and dental decay in 8,275 4(th) and 5(th) grade Kuwaiti children (average age = 11.36 years) in a cross-sectional study. First to determine body weight, height, age for computation of BMI . Second, to determine numbers of teeth, numbers of fillings and numbers of untreated decayed teeth to determine extent and severity of dental disease. From these measurements, we computed measures of dental decay in children from four body weight categories; obese, overweight, normal healthy weight and underweight children.

RESULTS

The percentage of children with decayed or filled teeth varied inversely with the body weight category. The percentage of decayed or filled teeth decreased from 15.61% (n=193) in underweight children, to 13.03% (n=4,094) in normal healthy weight children, to 9.73% (n=1,786) in overweight children to 7.87% (n=2,202) in obese children. Differences between all groups were statistically significant. Male children in this population had more dental decay than female children but the reduction of tooth decay as a function of BMI was greater in male children.

CONCLUSIONS

The finding of an inverse obesity-dental decay relationship contradicts the obesity-sugar and the obesity-dental decay relationship hypotheses. Sugar is well recognized as necessary and sufficient for dental decay. Sugar is also hypothesized to be a leading co-factor in obesity. If the later hypothesis is true, one would expect dental decay to increase with obesity. This was not found. The reasons for this inverse relationship are not currently clear.

Dental sealant knowledge, opinion, values and practice of Spanish dentists

BACKGROUND

Multiple guidelines and systematic reviews recommend sealant use to reduce caries risk. Yet, multiple reports also indicate that sealants are significantly underutilized. This study examined the knowledge, opinions, values, and practice (KOVP) of dentists concerning sealant use in the southwest region of Andalusia, Spain. This is a prelude to the generation of a regional plan for improving children's oral health in Andalusia.

METHODS

The survey's target population was dentists working in western Andalusia, equally distributed in the provinces of Seville, Cadiz, and Huelva (N=2,047). A convenience sample of meeting participants and meeting participant email lists (N=400) were solicited from the annual course on Community and Pediatric Dentistry. This course is required for all public health sector dentists, and is open to all private sector dentists. Information on the dentist's KOVP of sealants was collected using four-part questionnaire with 31, 5-point Likert-scaled questions.

RESULTS

The survey population demographics included 190 men (48%) and 206 women (52%) with an average clinical experience of 10.6 (±8.4) years and 9.3 (±7.5) years, respectively. A significant sex difference was observed in the distribution of place of work (urban/suburb) (p=0.001), but no sex differences between working sector (public/private). The mean±SD values for each of the four KOVP sections for pit and fissure sealants were: knowledge=3.57±0.47; opinion=2.48±0.47; value=2.74±0.52; and practice=3.48±0.50. No sex differences were found in KOVP (all p>0.4). Independent of sex: knowledge statistically differed by years of experience and place of work; opinion statistically differed by years of experience and sector; and practice statistically differed by years of experience and sector. Less experienced dentists tended to have slightly higher scores (~0.25 on a Likert 1-5 scale). Statistically significant correlations were found between knowledge and practice (r=0.44, p=0.00) and between opinion and value (r=0.35, p=0.00).

CONCLUSIONS

The results suggest that, similar to other countries, Andalusian dentists know that sealants are effective, have neutral to positive attitudes toward sealants; though, based on epidemiological studies, underuse sealants. Therefore, methods other than classical behavior change (eg: financial or legal mechanisms) will be required to change practice patterns aimed at improving children's oral health.

Causal association between smoking and tooth loss is highly likely

DATA SOURCES

Medline, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL) and hand searching of the journals; Community Dentistry and Oral Epidemiology, Gerodontology, Journal of Clinical Periodontology, Journal of Dental Research, Journal of Periodontology, Journal of Periodontal Research, Journal of Public Health Dentistry and Oral Diseases. Any potential studies in the reference lists of the identified articles read completely were also considered.

STUDY SELECTION

Studies published in English investigating associations between smoking and tooth loss and reporting the effect size were included. Literature reviews and studies that combined former smokers with non-smokers or current smokers were excluded.

DATA EXTRACTION AND SYNTHESIS

Data were extracted by one reviewer and verified independently by another with disagreements being resolved by discussion. Methodological quality of studies was assessed using the modified Newcastle-Ottawa Scale (NOS). A qualitative summary is presented.

RESULTS

Six cross-sectional and two cohort studies were included examining 58,755 subjects in four countries. All studies reported significant associations, although the strength of the association was usually moderate. Four studies reported dose-response relationships between exposure to smoking and the risk of developing tooth loss. A decrease in the risk of tooth loss for former smokers was evident in six studies. Interpretation of evidence for each element was consistent, despite some shortcomings regarding study type and population.

CONCLUSIONS

Based on the consistent evidence found with the existing biological plausibility, a causal association between smoking and tooth loss is highly likely. Further studies using a cohort design and different populations are necessary to confirm this association.