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)

Preventing Dental Caries in Children under 5 Years: Systematic Review Updating USPSTF Recommendation.

Pediatrics. 2013 Aug;132(2):332-50. doi: 10.1542/peds.2013-1469. Epub 2013 Jul15.Chou R, Cantor A, Zakher B, Mitchell JP, Pappas M.

BACKGROUND AND OBJECTIVE: Screening and preventive interventions by primary care 
providers could improve outcomes related to early childhood caries. The objective
of this study was to update the 2004 US Preventive Services Task Force systematic
review on prevention of caries in children younger than 5 years of age.
METHODS: Searching Medline and the Cochrane Library (through March 2013) and
reference lists, we included trials and controlled observational studies on the
effectiveness and harms of screening and treatments. One author extracted study
characteristics and results, which were checked for accuracy by a second author. 
Two authors independently assessed study quality.
RESULTS: No study evaluated effects of screening by primary care providers on
clinical outcomes. One good-quality cohort study found pediatrician examination
associated with a sensitivity of 0.76 for identifying a child with cavities. No
new trials evaluated oral fluoride supplementation. Three new randomized trials
were consistent with previous studies in finding fluoride varnish more effective 
than no varnish (reduction in caries increment 18% to 59%). Three trials of
xylitol were inconclusive regarding effects on caries. New observational studies 
were consistent with previous evidence showing an association between early
childhood fluoride use and enamel fluorosis. Evidence on the accuracy of risk
prediction instruments in primary care settings is not available.
CONCLUSIONS: There is no direct evidence that screening by primary care

clinicians reduces early childhood caries. Evidence previously reviewed by the US
Preventive Services Task Force found oral fluoride supplementation effective at
reducing caries incidence, and new evidence supports the effectiveness of
fluoride varnish in higher-risk children.