Fluoride Use in Caries Prevention in the Primary Care Setting

http://pediatrics.aappublications.org/content/early/2014/08/19/peds.2014-1699.full.pdf

Fluoride Use in Caries Prevention in the Primary Care Setting. Melinda B. Clark, Rebecca L. Slayton and SECTION ON ORAL HEALTH. Pediatrics; originally published online August 25, 2014; DOI: 10.1542/peds.2014-1699

[Comentario en una revista de noticias médicas online]
Pediatricians should prescribe fluoride as soon as their patients' teeth emerge, the American Academy of Pediatrics (AAP) says in new guidelines.
Pediatricians should prescribe fluoride as soon as their patients' teeth emerge, the American Academy of Pediatrics (AAP) says in new guidelines.
Published online August 25 in Pediatrics, the clinical report lays out specific recommendations for children at each stage of development.
Although the AAP endorsed the guidelines on fluoride use from the Centers for Disease Control and Prevention in 2001, it is only now incorporating them into its own publications.
Fluoride has both risks and benefits for children, and pediatricians must be aware of these to promote their patients' oral health, write report authors Melinda B. Clark, MD, and Rebecca L. Slayton, DDS, PhD.
Although largely preventable, dental caries remains the most common chronic childhood disease in the United States. Research long ago established the effectiveness of fluoride in stopping the progression of the disease.
Fluoride use does carry some risks. The best established risks are fluorosis, subsurface hypomineralization, and porosity between developing enamel rods. Fluorosis has been increasing the last 2 decades, as sources of fluoride have become more prevalent, and it now affects about 41% of US adolescents, the authors report.
In mild cases, fluorosis takes the form of clinically insignificant striations and opaque areas. Moderate to severe cases, which are rare in the United States, can cause pitting, brittle incisor edges, and weakened grove anatomy in permanent 6-year molars. However, the risk for fluorosis development largely passes by age 8 years.
Fluoride also can also be toxic when consumed in very large quantities. The authors estimate the toxic dose of elemental fluoride at 5 to 10 mg/kg body weight. For this reason, they recommend limiting the quantity prescribed at 1 time to no more than a 4-month supply and providing supervision for fluoride use by small children.

Dental interventions to prevent caries in children. A national clinical guideline

http://www.sign.ac.uk/pdf/SIGN138.pdf

Scottish Intercollegiate Guidelines Network (SIGN). Dental interventions to prevent caries in children. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2014 Mar. 45 p. Acceso a texto completo Major Recommendations Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline Clearinghouse (NGC): In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the full-text guideline document. The grades of recommendations (A-D) and levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field. Predicting Caries Risk Carries Risk Assessment C - The following factors should be considered when assessing caries risk: Clinical evidence of previous disease Dietary habits, especially frequency of sugary food and drink consumption Social history, especially socioeconomic status Use of fluoride Plaque control Saliva Medical history D - Specialist child healthcare professionals should consider carrying out a caries risk assessment of children in their first year as part of the child's overall health assessment. D - Children whose families live in a deprived area should be considered as at increased risk of early childhood caries when developing preventive programmes. Delivery of Dental Brief Interventions in the Practice Setting Effectiveness of Dental Brief Interventions B - Oral health promotion interventions should facilitate daily toothbrushing with fluoride toothpaste. Format of Dental Brief Interventions B - Oral health promotion interventions should be based on recognised health behaviour theory and models such as motivational interviewing. Social Determinants of Oral Health C - As part of the patient assessment, a social history should be taken which will contribute to dental brief interventions being specific to individuals and tailored to their particular needs and circumstances. Toothbrushing with Fluoride Toothpaste Concentration of Fluoride Toothpaste A - Following risk assessment, children and young people up to the age of 18 years who are at standard risk of developing dental caries should be advised to use toothpastes in the range 1,000 to 1,500 parts per million fluoride (ppmF). A - Following risk assessment, children aged from 10 to 16 years who are at increased risk of developing dental caries should be advised to use toothpastes at a concentration of 2,800 ppmF. Frequency and Duration of Brushing Frequency of Toothbrushing A - Toothbrushing with fluoride toothpaste should take place at least twice daily. Supervised Toothbrushing A - Supervision of toothbrushing with fluoride toothpaste is recommended as an effective caries prevention measure. Toothbrushing Practice A - Children should be encouraged to spit out excess toothpaste and not rinse with water after brushing. Topical Anticaries Interventions Topical Fluoride Varnish A - Fluoride varnish should be applied at least twice yearly in all children. Sealants Use of Sealants A - Resin-based fissure sealants should be applied to the permanent molars of all children as early after eruption as possible.

Prevention of Dental Caries in Children From Birth Through Age 5 Years: US Preventive Services Task Force Recommendation Statement

1. Virginia A. Moyer, MD, MPH 
2. on behalf of the US Preventive Services Task Force
3. 1. DESCRIPTION: Update of the 2004 US Preventive Services Task Force (USPSTF) recommendation on prevention of dental caries in preschool-aged children.
      METHODS: The USPSTF reviewed the evidence on prevention of dental caries by primary care clinicians in children 5 years and younger, focusing on screening for caries, assessment of risk for future caries, and the effectiveness of various interventions that have possible benefits in preventing caries.
      POPULATION: This recommendation applies to children age 5 years and younger.
      RECOMMENDATION: The USPSTF recommends that primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride. (B recommendation) The USPSTF recommends that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of routine screening examinations for dental caries performed by primary care clinicians in children from birth to age 5 years. (I Statement)

Fluoride varnishes for preventing dental caries in children and adolescents

Marinho VCC, Worthington HV, Walsh T, Clarkson JE

 The Cochrane Library 13 MAY 2013 DOI: 10.1002/14651858.CD002279.pub2

Abstract

Background

Topically-applied fluoride varnishes have been used extensively as an operator-applied caries-preventive intervention for over three decades. This review updates the first Cochrane review of fluoride varnishes for preventing dental caries in children and adolescents, which was first published in 2002.

Objectives

To determine the effectiveness and safety of fluoride varnishes in preventing dental caries in children and adolescents, and to examine factors potentially modifying their effect.

Search methods

We searched the Cochrane Oral Health Group's Trials Register (to 13 May 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 4), MEDLINE via OVID (1946 to 13 May 2013), EMBASE via OVID (1980 to 13 May 2013), CINAHL via EBSCO (1980 to 13 May 2013), LILACS and BBO via the BIREME Virtual Health Library (1980 to 13 May 2013), ProQuest Dissertations and Theses (1861 to 13 May 2013), and Web of Science Conference Proceedings (1945 to 13 May 2013). A search for ongoing trials was undertaken on ClinicalTrials.gov on 13 May 2013. There were no restrictions on language or date of publication in the search of the electronic databases.

Selection criteria

Randomised or quasi-randomised controlled trials with blind outcome assessment used or indicated, comparing topically-applied fluoride varnish with placebo or no treatment in children up to 16 years during at least one year. The main outcome was caries increment measured by the change in decayed, missing and filled tooth surfaces in both permanent (D(M)FS) and primary (d(e/m)fs) teeth.

Data collection and analysis

At least two review authors assessed all search results, extracted data and undertook risk of bias independently. Study authors were contacted for additional information. The primary measure of effect was the prevented fraction, that is the difference in mean caries increments between the treatment and control groups expressed as a percentage of the mean increment in the control group. The caries increments nearest to three years were used from each included study. Random-effects meta-analyses were performed where data could be pooled. Potential sources of heterogeneity were examined in random-effects meta-regression analyses. Adverse effects information was collected from the included trials.

Main results

Twenty-two trials with 12,455 participants randomised (9595 used in analyses) were included. For the 13 that contributed data for the permanent tooth surfaces meta-analysis, the pooled D(M)FS prevented fraction estimate comparing fluoride varnish with placebo or no treatment was 43% (95% confidence interval (CI) 30% to 57%; P < 0.0001). There was substantial heterogeneity, confirmed statistically (P < 0.0001; I² = 75%), however this body of evidence was assessed as of moderate quality. The pooled d(e/m)fs prevented fraction estimate was 37% (95% CI 24% to 51%; P < 0.0001) for the 10 trials that contributed data for the primary tooth surfaces meta-analysis, also with some heterogeneity (P = 0.009; I² = 59%). Once again this body of evidence was assessed as of moderate quality. No significant association between estimates of D(M)FS or d(e/m)fs prevented fractions and the pre-specified factors of baseline caries severity, background exposure to fluorides, application features such as prior prophylaxis, concentration of fluoride, frequency of application were found. There was also no significant association between estimates of D(M)FS or d(e/m)fs prevented fractions and the post hoc factors: whether a placebo or no treatment control was used, length of follow-up, or whether individual or cluster randomisation was used, in the meta-regression models. A funnel plot of the trials in the main meta-analyses indicated no clear relationship between prevented fraction and study precision. In both methods, power is limited when few trials are included. There was little information concerning possible adverse effects or acceptability of treatment.

Authors' conclusions

The conclusions of this updated review remain the same as those when it was first published. The review suggests a substantial caries-inhibiting effect of fluoride varnish in both permanent and primary teeth, however the quality of the evidence was assessed as moderate, as it included mainly high risk of bias studies, with considerable heterogeneity.

 

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Plain language summary

Fluoride varnishes for preventing dental caries in children and adolescents

Review question

The main question addressed by this review is how effective the use of fluoride varnish for the prevention of caries in children and adolescents is compared to placebo (a treatment without the active ingredient i.e. fluoride) or no treatment.

Background

Tooth decay (dental caries) is a significant health problem worldwide. It affects not only the vast majority of adults but also children, from 60% to 90% of them. In other words, six to nine children in every 10 are affected by tooth decay. Levels of tooth decay vary both between and within different countries, but it is generally true that children in lower socio-economic groups (measured by income, education and employment) have greater levels of tooth decay. Untreated tooth decay causes progressive destruction of the tops of teeth (crowns) and this is often accompanied by severe pain and suffering. Repairing and replacing decayed teeth is extremely costly in terms of time and money and is a major drain on the resources of healthcare systems.

The prevention of dental caries in children and adolescents is regarded as a priority for dental services and considered more cost-effective than its treatment. Fluoride is a mineral that prevents tooth decay. Fluoride is added to the water supply in many areas. It can also be applied directly to teeth in the form of fluoride varnish. This is applied to first (baby) and permanent teeth (depending on the age of the child) usually by a dental professional from two to four times a year. Because it stays on the surface of the tooth for relatively long periods of time it releases fluoride in an efficient and effective way.

Study characteristics

This review of existing studies was carried out by the Cochrane Oral Health Group and the evidence is current up to 13 May 2013.
In this updated review there are now 22 trials published between 1975 and 2012 in which a total of 12,455 children were randomised to treatment with either fluoride varnish or placebo/no treatment. Study duration ranged from one to five years among included trials (12 of these lasted two years).

Key results

The evidence produced has been found to be of moderate quality due to issues with trial designs. However in the 13 trials that looked at children and adolescents with permanent teeth the review found that the young people treated with fluoride varnish experienced on average a 43% reduction in decayed, missing and filled tooth surfaces. In the 10 trials looking at the effect of fluoride varnish on first or baby teeth the evidence suggests a 37% reduction in decayed, missing and filled tooth surfaces. There was little information concerning possible adverse effects or acceptability of treatment.

Quality of the evidence

The evidence presented is of moderate quality due to issues with trial designs.

Evidence-based clinical recommendations regarding fluoride intake from reconstituted infant formula and enamel fluorosis: a report of the American Dental Association Council on Scientific Affairs.

The Journal of the American Dental Association January 2011 vol. 142 no. 1 79-87

1. Joel Berg, DDS, 
2. Catherine Gerweck, DMD, MS, RD, 
3. Philippe P. Hujoel, MSD, PhD, 
4. Rebecca King, DDS, MPH, 
5. David M. Krol, MD, MPH,
6. Jayanth Kumar, DDS, MPH, 
7. Steven Levy, DDS, MPH, 
8. Howard Pollick, BDS, MPH, 
9. Gary M. Whitford, PhD, DMD, 
10. Sheila Strock, DMD, MPH,
11. Krishna Aravamudhan, BDS, MS, 
12. Julie Frantsve-Hawley, RDH, PhD,
13. Daniel M. Meyer, DDS and 
14. for the American Dental Association Council on Scientific Affairs Expert Panel on Fluoride Intake From Infant Formula and Fluorosis

Background. This article presents evidence-based clinical recommendations regarding the intake of fluoride from reconstituted infant formula and its potential association with enamel fluorosis. The recommendations were developed by an expert panel convened by the American Dental Association (ADA) Council on Scientific Affairs (CSA). The panel addressed the following question: Is consumption of infant formula reconstituted with water that contains various concentrations of fluoride by infants from birth to age 12 months associated with an increased risk of developing enamel fluorosis in the permanent dentition?

Types of Studies Reviewed. A panel of experts convened by the ADA CSA, in collaboration with staff of the ADA Center for Evidence-based Dentistry (CEBD), conducted a MEDLINE search to identify systematic reviews and clinical studies published since the systematic reviews were conducted that addressed the review question.

Results. CEBD staff identified one systematic review and two clinical studies. The panel reviewed this evidence to develop recommendations.

Clinical Implications. The panel suggested that when dentists advise parents and caregivers of infants who consume powdered or liquid concentrate infant formula as the main source of nutrition, they can suggest the continued use of powdered or liquid concentrate infant formulas reconstituted with optimally fluoridated drinking water while being cognizant of the potential risks of enamel fluorosis development. These recommendations are presented as a resource to be considered in the clinical decision-making process. As part of the evidence-based approach to care, these clinical recommendations should be integrated with the practitioner’s professional judgment and the patient’s needs and preferences.

Texto completo en PDF: http://jada.ada.org/content/142/1/79.full.pdf+html

Evidence-Based Clinical Recommendations on the Prescription of Dietary Fluoride Supplements for Caries Prevention

A Report of the American Dental Association Council on Scientific Affairs

This article presents evidence-based clinical recommendations for the prescription of dietary fluoride supplements. The recommendations were developed by an expert panel convened by the American Dental Association (ADA) Council on Scientific Affairs (CSA). The panel addressed the following questions: when and for whom should fluoride supplements be prescribed, and what should be the recommended dosage schedule for dietary fluoride supplements?

Acceso a texto completo

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.

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.