Revisión sistemática sobre la caries en niños y adolescentes con obesidad y/o sobrepeso

María González Muñoz1, Milagros Adobes Martín1 y Javier González de Dios
Nutr Hosp. 2013;28(5):1372-1383

Resumen
Introducción: Obesidad y el sobrepeso (O/SP) infantil han alcanzado caracteres de epidemia y son un factor de riesgo de enfermedades crónicas graves para la salud. El objetivo es realizar una revisión sistemática (RS) sobre la relación de O/SP con caries en pediatría.

Material y métodos: RS de la literatura 2007-2011 en fuentes de información terciaria (Trip, Cochrane y
NGC), secundaria (PubMed, IME, IBECS y MEDES) y primarias (revisión de referencias). Criterios de inclusión: Pacientes (niños de 0-18 años), factor de riesgo (O/SP) y variable de interés (primaria: caries; secundarias: resto patología bucodental). Datos recogidos: Autor, año, país, tipo de estudio, edad pacientes, casos (con O/SP) y controles (con índice de masa corporal —IMC— normal o bajo), estado socioeconómico, prevalencia de caries y otros resultados en salud bucodental.

Resultados: Se localizaron un total de 48 documentos, de los que 37 cumplieron los criterios de búsqueda de la RS, distribuidos temporalmente: 6 artículos del año 2007, 6 del 2008, 5 del 2009, 11 del 2010 y 9 del 2011. Presentaron un grado de heterogeneidad muy amplio (en pacientes, intervención, variable principal de interés y tipo de diseño), lo que no permite aplicar síntesis cuantitativa (metanálisis) de los datos, pero si cualitativa. Los estudios son discordantes respecto a la relación entre IMC y frecuencia de caries (CAOD, caod).

Conclusiones: La RS permite al odontólogo y pediatra conocer la potencial relación entre O/SP y caries dental.

Guideline on Xylitol Use in Caries Prevention

Council on Clinical Affairs. Guideline on xylitol use in caries prevention. Chicago (IL): American Academy of Pediatric Dentistry (AAPD); 2011. 4 p. [51 references]

Recommendations

Clinicians may consider recommending xylitol use to moderate or high caries risk patients. Those recommending xylitol should be familiar with the product labeling and recommend age-appropriate products. They should routinely reassess (not less than once every 6 months) a patient for changes in caries-risk status and adjust recommendations accordingly.

Dosage

There is accumulating evidence that total daily doses of 3 to 8 grams of xylitol are required for a clinical effect with the currently available delivery methods of syrup, chewing gum, and lozenges. Dosing frequency should be a minimum of 2 times a day, not to exceed 8 grams per day. Although tables of clinically effective xylitol containing products have recently been published, the products are continually changing.

Modality

Chewing gum has been the predominant modality for xylitol delivery in clinical studies. Studies that have utilized xylitol-containing mints and hard candies have shown them to be as effective as xylitol-containing chewing gum. The American Academy of Pediatrics (AAP) does not recommend use of chewing gum, mints, or hard candy by children less than 4 years of age due to the risk of choking. A randomized trial of xylitol syrup (8 g/day) reduced early childhood caries by 50 to 70 percent in children 15 to 25 months of age. Another study showed that gum or lozenges consumed by children at 5 grams total dose per day at about age 10 resulted in 35 to 60 percent reductions of tooth decay, with no differences between the delivery methods. Xylitol containing gummy bears, other confections, and even milk have been studied as delivery vehicles, but they are neither well established scientifically nor available commercially at present. A pacifier with a pouch containing slow release xylitol in tablet form, not yet available in the United States, has shown high salivary xylitol concentrations and may be a potential delivery vehicle for infants. Currently, xylitol-containing chewing gum, mints, energy bars and foods, nasal sprays, and oral hygiene products (e.g., mouth rinse, gels, wipes, floss) are commercially available through retail or online venues. However, they may not contain the necessary therapeutic level, xylitol as the only sweetener, or adequate labeling.

Studies using toothpaste formulations with 10% xylitol (dose of 0.1 g/brushing) have shown reduction in m

Effectiveness of Preventive Dental Treatments by Physicians for Young Medicaid Enrollees

Pahel BT, Rozier RG, Stearns SC, Quiñonez RB
Pediatrics. 2011;127(3):e682-e689 (doi:10.1542/peds.2010-1457)

OBJECTIVE To estimate the effectiveness of a medical office–based preventive dental program (Into the Mouths of Babes [IMB]), which included fluoride varnish application, in reducing treatments related to dental caries.

METHODS We used longitudinal claims and enrollment data for all children aged 72 months or younger enrolled in North Carolina Medicaid from 2000 through 2006. Regression analyses compared subgroups of children who received up to 6 IMB visits at ages 6 to 35 months with children who received no IMB visits. Analyses were adjusted for child and area characteristics.

RESULTS Children enrolled in North Carolina Medicaid with 4 IMB visits experienced, on average, a 17% reduction in dental-caries–related treatments up to 6 years of age compared with children with no IMB visits. When we simulated data for initial IMB visits at 12 and 15 months of age, there was a cumulative 49% reduction in caries-related treatments at 17 months of age. The cumulative effectiveness declined because of an increase in treatments from 24 to 36 months, an increase in referrals for dental caries occurred with increasing time since fluoride application, and emergence of teeth not initially treated with fluoride.

CONCLUSIONS North Carolina's IMB program was effective in reducing caries-relatedtreatments for children with 4 IMB visits. Multiple applications of fluoride at the time of primary tooth emergence seem to be most beneficial. Referrals to dentists for treatment of existingdisease detected by physicians during IMB implementation limited the cumulative reductions in caries-related treatments, but also contributed to improved oral health.

Strategies to prevent dental caries in children and adolescents: evidence-based guidance on identifying high caries risk children and developing preve

Strategies to prevent dental caries in children and adolescents: evidence-based guidance on identifying high caries risk children and developing preventive strategies for high caries risk children in Ireland.
Irish Oral Health Services Guideline Initiative. Strategies to prevent dental caries in children and adolescents: evidence-based guidance on identifying high caries risk children and developing preventive strategies for high caries risk children in Ireland. Cork (Ireland): Oral Health Services Research Centre; 2009. 90 p
Preventive Strategies

Oral health messages should be incorporated into relevant general health promotion interventions for children and adolescents as part of a common risk factor approach to improving oral health. [D]

Diet

Oral health education to parents/carers, children and adolescents should encourage healthy eating, in line with national dietary guidelines. [D]
Parents/carers should be encouraged to limit their child's consumption of sugar-containing foods and drinks, and when possible, to confine their consumption to mealtimes. [D]
Children and adolescents should be encouraged to limit their consumption of sugar-containing foods and drinks, and when possible, to confine their consumption to mealtimes. [D]
Parents and carers of children who use a baby bottle should be advised never to put sweet drinks, including fruit juice, into the bottle. [C]
Parents and carers should be advised not to let their child sleep or nap with a baby bottle or feeder cup. [GPP]
Parents/carers and children should be advised that foods and drinks containing sugar substitutes are available, but should be consumed in moderation. [D]
Sugar-free medicines should be used, when available. [D]
Topical Fluorides

Under 2 Years of Age: At Risk Children

Parents/carers should be encouraged to brush their child's teeth as soon as the first tooth appears, using a soft toothbrush and water only. [D]
Under 2 Years of Age: High Caries Risk Children

Parents/carers of children who are assessed as being at high caries risk should be encouraged to brush their child's teeth:
With fluoride toothpaste containing at least 1,000 parts per million fluoride (ppm F) [A]
Twice a day [B]
At bedtime and one other time during the day [GPP]
Using a small pea size amount of toothpaste [D]
Age 2 Years and Over
......

Guideline on fluoride therapy.

Guideline on fluoride therapy.

American Academy of Pediatric Dentistry Liaison with Other Groups Committee, American Academy of Pediatric Dentistry Council on Clinical Affairs. Guideline on fluoride therapy. Pediatr Dent 2008-2009;30(7 Suppl):121-4.


MAJOR RECOMMENDATIONS
If an individual's caries risk level is uncertain, treating this person as high risk is prudent until further experience allows a more accurate assessment.
Systemically Administered Fluoride Supplements
Fluoride supplements should be considered for all children drinking fluoride-deficient (<0.6 parts per million [ppm]) water. After determining the fluoride level of the water supply or supplies (either through contacting public health officials or water analysis), evaluating other dietary sources of fluoride, and assessing the child's caries risk, the daily fluoride supplement dosage can be determined using the Dietary Fluoride Supplementation Schedule (see the table below). To optimize the topical benefits of systemic fluoride supplements, the child should be encouraged to chew or suck fluoride tablets.

Age	<0.3>	0.3-0.6 ppm F	>0.6 ppm F
Birth-6 months	0	0	0
6 months-3 years	0.25 mg	0	0
3-6 years	0.50 mg	0.25 mg	0
6 years up to at least 16 years	1.00 mg	0.50 mg	0

Professionally-Applied Topical Fluoride Treatment
Professional topical fluoride treatments should be based on caries-risk assessment. A pumice prophylaxis is not an essential prerequisite to this treatment. Appropriate precautionary measures should be taken to prevent swallowing of any professionally-applied topical fluoride. Children at moderate caries risk should receive a professional fluoride treatment at least every 6 months; those with high caries risk should receive greater frequency of professional fluoride applications (i.e., every 3-6 months). Ideally, this would occur as part of a comprehensive preventive program in a dental home. When a dental home cannot be established for individuals with increased caries risk as determined by caries risk assessment, periodic applications of fluoride varnish by trained non-dental healthcare professionals may be effective in reducing the incidence of early childhood caries.
Fluoride-Containing Products for Home Use
Therapeutic use of fluoride for children should focus on regimens that maximize topical contact, preferably in lower-dose, higher-frequency approaches. Fluoridated toothpaste should be used twice daily as a primary preventive procedure. Twice daily use has benefits greater than once daily brushing. Parents should be counseled on their child's caries risk, dispensing an appropriate volume of toothpaste onto a soft, age-appropriate sized toothbrush, frequency of brushing, and performing/assisting brushing of young children. A 'smear' of fluoridated toothpaste for children less than 2 years of age may decrease risk of fluorosis. A 'pea-size' amount of toothpaste is appropriate for children aged 2 through 5 years. To maximize the beneficial effect of fluoride in the toothpaste, rinsing after brushing should be kept to a minimum or eliminated altogether.
Additional at-home topical fluoride regimens utilizing increased concentrations of fluoride should be considered for children at high risk for caries. These may include over-the counter or prescription strength formulations. Fluoride mouth rinses or brush-on gels may be incorporated into a caries-prevention program for a school-aged child at high risk.