Guidelines on the use of fluoride for caries prevention in children: an updated EAPD policy document

Concentration of Fluoride in Saliva After Fluoride Gel Application: A Randomised Clinical Trial

OBJECTIVE

The aim of this randomised clinical trial (RCT) was to assess the concentration of fluoride ions in saliva after applying fluoride gel and to examine the extent to which rinsing the mouth with water affects the content of fluoride ions in saliva as opposed to no rinsing after brushing teeth with gel.

METHODS

This single-blind RCT was conducted amongst a group of students (N = 103) and consisted of a questionnaire, clinical examination, saliva collection, and laboratory analysis. After saliva samples were collected, the students brushed their teeth for 2 minutes with Elmex Gelée (Colgate-Palmolive). Next, saliva was collected after 15 and 60 minutes from Group A (spitting out saliva after brushing) and from Group B (spitting out and rinsing with water after brushing). Statistical analysis was performed using a t test to compare the means between the groups.

RESULTS

Fifteen minutes after brushing, the level of fluoride increased in Group A about 15-fold to 15.33 ± 14.73 ppm and in Group B about 6-fold to 6.19 ± 5.97 ppm (P < .001). After 60 minutes, in Group A it decreased to 1.68 ± 0.83 ppm and in Group B to 0.60 ± 0.37 ppm (P < .001).

CONCLUSIONS

The use of fluoride gel in the absence of mouth rinsing produced significantly higher level and a concentration of fluoride in saliva. A post-gel brushing without rinsing might be suitable for patients at high risk for caries. Hence fruther research on the effect of a mouth rinse after use of fluoride gels is eesential to confirm our findings, and to promulgate evidence-based recommendations.

Factors associated with toothbrushing performance among children: An observational cohort study

BACKGROUND

Effective removal of dental plaque is essential factor for prevention of caries, gingival, and periodontal diseases in children and adults.

AIM

To evaluate factors associated with improving toothbrushing performance (TB-P) among children.

DESIGN

An observational cohort study analyzed all paediatric patients receiving regular examinations in a single dental clinic between 2009 and 2017 and regularly brushing their teeth with a triple-headed toothbrush (TH-TB). At every periodic follow-up, the TB-P of the child/parent was evaluated using the TB-P Skill Index (TB-PS-I); that is, did the child reach all five teeth segments within each arch and did he/she perform 10 back-and-forth stocks in each segment. When not optimal, they received instructions for improving TB-P and subsequently were asked to re-demonstrate. TB-PS-I was calculated and analyzed for correlation with other explanatory variables.

RESULTS

A total of 1737 children with 7399 follow-up appointments were analyzed. Older age, female gender, higher number of follow-up appointments, and compliance with twice-daily toothbrushing significantly improved TB-P. The most typical mistakes in their performance were not reaching the canine segments and not performing enough strokes in each segment. Instructions given after imperfect TB-P significantly improved the TB-P. The magnitude of improvement, however, did not correlate with the performers' age, gender, or the number of follow-up visits.

CONCLUSIONS

A significant percentage of children >8 years did not perform optimal toothbrushing even when using TH-TB.

The factors associated with the knowledge of brushing teeth with fluoridated toothpaste among high school students in Al-Madinah, Saudi Arabia

Objective

The use of fluoridated toothpaste (FT) is essential for controlling caries. This analytical cross-sectional study aimed to determine the proportion of students who brushed their teeth with fluoridated toothpaste/or do not know the content at least once a day and to determine the factors associated with the knowledge of brushing teeth with FT.

Methods

An anonymous questionnaire was distributed during the academic year 2019-2020 among 439 high school students. The data collected included sociodemographic characteristics and oral-health-related variables [e.g., brushing teeth, knowledge of the effect of fluoride on caries (KEFC) and dental service utilisation (DSU)]. The dependent variable was the knowledge of using FT when brushing teeth (Yes or do not know). Descriptive, bivariate, and logistic regression analysis were performed.

Results

The response rate was 98% (n = 432) and usable data was 88% (n = 385). The median (IQR) age of the students was 16.00 (1) years, and 190 (47%) were males. Eighty eight percent of the students brushed their teeth with toothpaste daily with no knowledge of toothpaste content and only 86 (21.8%) knew the content of the toothpaste used for brushing their teeth i.e., FT. The multivariable analyses revealed an association of family income and KEFC with brushing teeth with FT [adjusted odds ratio (AOR): 1.98, 95% confidence interval (CI): 1.14-3.43, p = 0.015 and AOR = 6.11, 95% CI: 3.45-10.83, p < 0.001, respectively].

Conclusions

While the brushing and use of toothpaste among high school students was common, the knowledge of the content of toothpaste used for brushing teeth was less common and was associated with family income and KEFC.

Are parental sociodemographic factors, oral health knowledge and practices linked to the oral health habits of their children with cleft lip and palate?

OBJECTIVE

Children with cleft lip and palate (CLP) have a greater risk of dental caries. The parents' knowledge and attitudes may have an impact on their children's oral health and dietary habits. Therefore, the aim of this study was to assess the socio-demographic characteristics, oral health knowledge, oral health behaviours, and habits of the parents in addition to the relationship with the oral health and dietary practices of their children with CLP.

MATERIAL AND METHODS

The parents of 343 patients with CLP participated in the study. An online questionnaire with 52 questions regarding sociodemographic characteristics, oral health and oral hygiene practices was presented to them.

RESULTS

Parents with higher level of education had better oral health knowledge (p < 0.05). Logistic regression analysis showed that the factors affecting the child's tooth brushing habits were the mother's age (odds ratio [OR] = 1.071, 95% confidence interval [CI]: 1.062-1.153), the father's employment status (OR = 2.089, 95%CI: 1.065-4.097), and the mother's last dental visit (OR = 1.995, 95%CI: 1.119-3.557). The factors affecting the child's toothpaste usage were the mother's age (OR = 1.106, 95%CI: 1.030-1.114), the father's employment status (OR = 2.124, 95%CI: 1.036-4.354), and the mother's last dental visit (OR = 2.076, 95%CI: 1.137-3.79).

CONCLUSIONS

Parental factors have a significant influence on the oral health-related behaviours of children with CLP.

Comparative study of the dental health of 4-year-old children in north-eastern France between 2001 and 2018

PURPOSE

To analyse the evolution of the oral health of 4-year-old children in nursery school between 2001 and 2018 as well as the early predictor and associated risk factors, in different school areas.

METHODS

We compared (1) the prevalence of ECC (4 ≥ dmft ≥ 1) and S-ECC (dmft ≥ 5) of 4-year-old children and (2) data obtained by a structured questionnaire completed by their parents from two studies performed in 2001 and 2018. Data were analysed using the Chi2 test and odds ratio (OR).

RESULTS

A total of 322 children and of 425 children randomly selected among Moselle's public nursery schools in north-eastern France were, respectively, included in the study in 2001 and 2018. The prevalence of ECC was respectively 40.70% and 21.65% in 2001 and 2018 (p < 0.001; OR = 2.48; 95% CI = 1.78-3.47). We also observed a decrease of S-ECC prevalence (10.56% in 2001 vs 5.90% in 2018, p < 0.05, OR = 1.89; 95% CI = 1.07-3.38). The intake of cariogenic food (sweet drink, biscuits, candies, milk, baby bottle) decreased but the knowledge of parents concerning cariogenic food did not improve. The proportion of parents helping their child has not changed in 17 years (82.33% vs 86.52%, p > 0.1) but tooth brushing was initiated earlier in 2018 than in 2001 (p < 0.01). Prescription of systemic fluoride decreased (39.14% vs 3.62%; p < 0.001).

CONCLUSION

The identification of the food consumption habits and the knowledge of parents concerning oral health should enable strengthening of preventive measures and the initiation of an oral health education programme for children and their family.

Postoperative instructions for silver diamine fluoride therapy: A scoping review of current evidence and practice

OBJECTIVES

Silver diamine fluoride (SDF) has gained popularity in dentistry as an anti-hypersensitive and anti-caries agent. This study aims to review the postoperative instructions for SDF therapy and examine the evidence supporting these instructions in treating dentine hypersensitivity and caries control.

DATA AND SOURCES

Two independent reviewers searched three electronic databases (EMBASE, PubMed, and Web of Science) to identify clinical studies that used SDF to treat dentine hypersensitivity and dental caries. Additionally, they searched Google Chrome for information from manufacturers, the department of health, national dental organisations, authoritative dental organisations, and universities regarding SDF therapy for these conditions. Data on postoperative instructions were extracted, and their impact on the treatment of dentine hypersensitivity and caries control was investigated.

STUDY SELECTION

This review included 74 clinical studies, 11 sets of instructions from SDF manufacturers, and six recommendations from national dental organisations, departments of health and universities. Amongst the included records, 50 clinical studies, two manufacturers, and one department of health mentioned postoperative instructions for SDF therapy. The recommendations varied, from suggesting no specific instructions, immediate rinsing, refraining from eating or drinking for 30 to 60 min, and even avoiding brushing until the next day after SDF therapy. Notably, no clinical studies reported the effects of these postoperative instructions on the SDF treatment of dentine hypersensitivity or dental caries.

CONCLUSIONS

This scoping review highlights the presence of inconsistent postoperative instructions for SDF therapy in the treatment of dentine hypersensitivity and caries control. Furthermore, there is a lack of evidence supporting the effectiveness of these instructions.

CLINICAL SIGNIFICANCE

No evidence supports the postoperative instructions for SDF therapy for managing dentine hypersensitivity and dental caries. Studies are necessary to provide guidance for clinicians using SDF in their clinical practice.

Hypomineralised second primary molars: the Würzburg concept

PURPOSE

In addition to molar incisor hypomineralisation, the occurrence of enamel hypomineralisation in the primary dentition has become increasingly important in recent years. Hypomineralised second primary molar (HSPM) is defined as hypomineralisation of systemic origin affecting from one to all four second primary molars. Some years ago, the "Würzburg concept" was introduced, which proposed a grading of MIH findings (MIH treatment need index) in combination with an appropriate treatment plan depending on the severity of the affected tooth. Recently, this concept was updated and new treatment approaches have been added. However, currently, the concept solely addresses the treatment plan for permanent teeth. As there is a need to expand its scope to encompass primary teeth and, consequently, HSPM, this paper seeks to develop the second component of the Würzburg concept, the treatment plan, for the primary dentition in response to the increased focus on the disease in recent years. Although the evidence base for the different treatment options is still weak, there is a need for guidance for clinicians in their day-to-day practice.

METHODS

The authors conducted a comprehensive review of the literature, encompassing clinical and laboratory studies along with published guidelines.

RESULTS

The treatment plan of the HSPM Würzburg concept contains prophylactic and regenerative aspects, non-invasive interventions, temporary and permanent restorative techniques, and extraction.

CONCLUSIONS

The intention is to provide practical guidance to practitioners, acknowledging the necessity for further validation through clinical trials.

Plant-Derived Compounds: A Promising Tool for Dental Caries Prevention

There is a growing shift from the use of conventional pharmaceutical oral care products to the use of herbal extracts and traditional remedies in dental caries prevention. This is attributed to the potential environmental and health implications of contemporary oral products. This comprehensive review aims at the analysis of plant-derived compounds as preventive modalities in dental caries research. It focuses on data collected from 2019 until recently, trying to emphasize current trends in this topic. The research findings suggest that several plant-derived compounds, either aqueous or ethanolic, exhibit notable antibacterial effects against Streptococcus mutans and other bacteria related to dental caries, with some extracts demonstrating an efficacy comparable to that of chlorhexidine. Furthermore, in vivo studies using plant-derived compounds incorporated in food derivatives, such as lollipops, have shown promising results by significantly reducing Streptococcus mutans in high-risk caries children. In vitro studies on plant-derived compounds have revealed bactericidal and bacteriostatic activity against S. mutans, suggesting their potential use as dental caries preventive agents. Medicinal plants, plant-derived phytochemicals, essential oils, and other food compounds have exhibited promising antimicrobial activity against oral pathogens, either by their anti-adhesion activity, the inhibition of extracellular microbial enzymes, or their direct action on microbial species and acid production. However, further research is needed to assess their antimicrobial activity and to evaluate the cytotoxicity and safety profiles of these plant-derived compounds before their widespread clinical use can be recommended.

Should we be concerned about the use of non-fluoride toothpaste? A survey study in two European countries

BACKGROUND

Toothpastes available in Europe contain a range of fluoride concentrations, with some meeting the recommended level for caries prevention (>1000 ppm fluoride (ppm)) and others containing low or no fluoride. This study evaluated toothpaste fluoride concentrations in Latvia and Lithuania to inform targeted public health strategies in regions with a high prevalence of dental caries.

METHODS

This cross-sectional study was conducted from May 2019 to May 2020, using a validated questionnaire in Latvia and Lithuania. Nationally representative samples (1309 families and 5436 members) provided data through a mixed-mode survey (paper and online) on sociodemographic information, toothpaste type, brand, and type. Descriptive statistics and chi-square tests (p < 0.05) were used for analysis.

RESULTS

Fifteen percent of families used non-fluoridated toothpaste and 12% used <1000 part per million (ppm) fluoride. In Latvia, 56.8% of preschoolers and 28.7% of schoolchildren used <1000 ppm or non-fluoride toothpaste, whereas in Lithuania, 47.2% of preschoolers and 29.1% of schoolchildren used <1000 ppm or non-fluoride toothpaste; 63% of adolescents and 73% of adults used toothpaste with optimal fluoride content (≥1000 ppm). Of the 228 registered toothpaste types, 62% contained more than 1000 ppm, which is optimal for caries prevention; 29% of Latvian and 24% of Lithuanian families used at least one non-fluoridated toothpaste.

CONCLUSION

This study revealed significant gaps in the use of fluoride toothpaste among families in Latvia and Lithuania, especially among children. To effectively prevent dental caries, targeted interventions, and education must promote optimal fluoride toothpaste use, particularly among vulnerable populations.

Amount of Dentifrice and Fluoride Concentration Affect the pH and Inorganic Composition of Dual-Species Biofilms of Streptococcus mutans and Candida albicans

This work assessed the influence of the amount of dentifrice and fluoride (F) concentration in the product on the pH and inorganic components of Streptococcus mutans and Candida albicans dual-species biofilms. The biofilms were treated with suspensions of fluoride dentifrices containing 550 or 1100 ppm of F (550 F or 1100 F, respectively) administered at comparable intensities: (i-1) 550 F/0.08 g or 1100 F/0.04 g; (i-2) 550 F/0.16 g or 1100 F/0.08 g; and (i-3) 550 F/0.32 g or 1100 F/0.16 g. A placebo dentifrice (without NaF, 0.32 g) was used as a negative control. After the last treatment, the biofilm pH was measured and the F, calcium (Ca), and phosphorus (P) concentrations were determined. Data were subjected to an ANOVA/Kruskal-Wallis test, and a Student-Newman-Keuls test. The highest biofilm pH and F concentrations (biomass and fluid) were observed for 1100 F at i-3. Overall, 1100 F resulted in F levels similar to 550 F for i-1 and i-2. In addition, 550 F applied at i-2 and i-3 led to higher F in the biomass/fluid compared to 1100 F applied at i-1 and i-2, respectively. In biomass, the lowest Ca concentrations were observed for 1100 F at i-3. The conclusion drawn is that the treatment intensity holds greater significance as a parameter compared to the concentration of F or the amount of dentifrice when considered individually.

A Comparison of the Fluoride 'Paint- On' vs Tray Application Techniques for Enamel Remineralisation

BACKGROUND

Fluoride gel treatment is not recommended for children < 6 years old due to its potential toxicity. Hence the aim of this study was to compare the effect of 1.23% acidulated-phosphate fluoride (APF) gel paint-on and the conventional tray application techniques on artificial, deciduous enamel carious lesions embedded on wearable appliances.

METHODS

In a randomised crossover study, the volunteer children (n = 29) wore mandibular removable appliances containing embedded tooth specimens with artificial carious lesions. The volunteers had 3 different treatment protocols: (I) 0.4 mL non-fluoride (control) gel, (II) 0.4 mL paint-on 1.23% APF gel or (III) 5 mL 1.23% APF gel, 4 minutes tray application. After 1 hour, the appliances were removed and the specimens underwent an in vitro, 14 days of pH-cycling. The mean percentage reduction in fluorescence (ΔF, %) at baseline (ΔF0) and after the pH-cycling (ΔF1) were determined using quantitative light-induced fluorescence-digital analysis. The mean ΔΔF (ΔF1-ΔF0) was calculated to compare the differences between groups.

RESULTS

The mean ΔΔF of groups I to III were -1.42 ± 1.49, 1.06 ± 2.11, and 1.12 ± 3.57 and -1.25 ± 1.44, 1.13 ± 1.84 and 1.44 ± 3.62 for the smooth surface and proximal surface lesions, respectively. The mean ΔΔF in the 2 treatment groups were significantly greater compared with the control group (P < .001). There was no significant difference in ΔΔF between the APF gel tray and paint-on groups either in the smooth surfaces, or the proximal surfaces (P = .629 and P = .613, respectively).

CONCLUSION

Our study, for the first time, indicates that the paint-on application of APF gel or the tray application of APF had a similar enamel remineralisation effect. Clinically, this implies that, particularly in younger children, the paint-on application of fluoride is less cumbersome, and possibly more tolerable with a lesser likelihood of fluoride ingestion than the tray application technique.

TRIAL REGISTRATION

Thai Clinical Trial Registry (https://www.thaiclinicaltrials.org/show/TCTR20190724001).

Caries Etiology and Preventive Measures

Caries is a widespread disease in both children and adults. Caries is caused by the conversion of fermentable carbohydrates by plaque bacteria into acids on the tooth surface. Thus, it is important to focus on sugar reduction and plaque control. For efficient plaque removal/control, state-of-the-art toothpastes contain various active ingredients such as antimicrobial agents (e.g., chlorhexidine, stannous salts, and zinc salts), abrasives (e.g., calcium carbonate, calcium phosphates, and hydrated silica), surfactants (e.g., sodium lauryl sulfate and sodium methyl cocoyl taurate), and natural compounds (e.g., polyphenols and xylitol). Agents with pH-buffering and calcium-releasing properties (e.g., calcium carbonate and calcium phosphates) and biomimetic actives (e.g., hydroxyapatite) reverse the effects of the acids. Additionally, modern toothbrushes (i.e., electric toothbrushes) as well as dental floss and interdental brushes significantly help remove plaque from dental surfaces including interproximal surfaces. In conclusion, modern concepts in caries prevention should focus not only on tooth remineralization alone but also on the control of all the key factors involved in caries development.

Control of Dental Caries in Children and Adolescents Using Fluoride: An Overview of Community-Level Fluoridation Methods

The maintenance of oral health is a crucial aspect of general well-being; however, a significant proportion of the worldwide population experiences a range of oral diseases. Dental caries is a highly prevalent non-communicable disease globally, especially in children and adolescents. Fluoride is involved in the control of dental caries, primarily by decreasing the critical pH for dental hard tissue dissolution and decreasing enamel solubility. Due to the substantial data supporting the efficacy of fluoride in controlling dental caries, many community-level fluoridation initiatives have been devised and executed as global public health preventive interventions. These initiatives encompass the fluoridation of water, salt, and milk. Water fluoridation is considered safe and effective when fluoride levels are maintained within the recommended range (0.6 to 1.1 mg/L). Salt fluoridation has a cariostatic potential similar to that of water fluoridation, and a fluoride concentration of 250 micrograms per gram in salt is not associated with an increased risk of developing dental fluorosis. However, there is currently an effort to reduce the consumption of table salt in order to mitigate the harmful effects of excessive salt consumption. It has been hypothesized that fluoride food supplementation, such as fluoridated milk, is associated with a decrease in caries experience in permanent teeth; however, the effect is not clear in primary teeth. Public-level fluoride interventions are more cost-effective than the operative care of caries lesions and limit the burden of care. The administration of fluorides should be conducted using safe methods, limiting ingestion, and adhering to the guidelines set by international and national health agencies in each country. This is particularly important when considering children with developing dentitions. Fluoride is an important tool in the control of dental caries, but it is crucial to combine it with good oral hygiene, a healthy diet, and regular visits to a dental professional to maintain long-term oral health.

Dental Practice Websites in Germany-How Do They Inform about Fluoridation?

Fluoridation (Fl) is effective in preventing caries; however, it is unclear to what extent its use is counteracted by misinformation on the internet. This study aimed to evaluate the information provided on professional websites of German dental practices regarding fluoridation. A systematic search was performed by two independent examiners, utilizing three search engines, from 10 September 2021 to 11 December 2021. Modified, validated questionnaires (LIDA, DISCERN) were used to evaluate technical and functional aspects, generic quality, and risk of bias. Demographic information and statements about Fl were also collected. The intra- and inter-rater reliability assessments were excellent. Of the 81 websites analyzed, 64 (79%) mentioned Fl, and 31 (38%) indicated it as a primary focus. Most websites met at least 50% of the LIDA (90%) and DISCERN criteria (99%), indicating that the general quality was good. Thirty (37%) of the websites explained the impact of Fl, and forty-five (56%) indicated an opinion (for/against) on Fl. The practice location and the clinical focus were not associated with the overall quality of websites. Only a minority of websites explained the effects of Fl. Taken together, this study highlights that there is a distinct lack of good-quality information on FL.

The impact of bias of underlying literature in guidelines on its recommendations: assessment of the German fluoride guideline

PURPOSE

The significance of the underlying literature in clinical guidelines can be weakened by the risk of bias, which could negatively affect the recommendations. Especially in controversial matters, such as fluoride use for caries prevention in children, biased results may be not reliable and lead to incorrect conclusions. This study was performed to detect bias in underlying literature of the German guideline for caries prevention using fluoride in children, where no consensus was reached between paediatricians and paediatric dentists.

METHODS

Three tools used for risk of bias assessments of different study designs were RoB 2 for RCTs, ROBINS-I for non-randomized studies, and ROBIS for systematic reviews. For each study cited in the guideline two independent risk of bias assessments were performed. Disagreements were resolved by consensus.

RESULTS

Out of 58 papers, 48.3% (n = 28) showed high risk of bias, with the majority in sections regarding fluoride tablets, fluoridated toothpaste, and paediatricians' recommendations. 9 out of 20 recommendations and statements were based on studies with high risk of bias, all of which were in these three controversial sections. 13 out of 29 RCTs showed high risk of bias (44.8%), as all 13 non-randomized trials did, while only 2 of 16 (12.5%) systematic reviews had high risk of bias.

CONCLUSION

Considering risk of bias of cited studies in clinical guidelines may result in substantial changes in its recommendations and aid in reaching consensus. Efforts should be made to assess risk of bias of underlying literature in future clinical guidelines.

Doses of fluoride toothpaste for children up to 24 months

AIM

The aim of this study was to test the dose of fluoride toothpaste by parents for their children aged up to 24 months.

METHODS

Parents who use fluoride toothpastes for their children were asked to dose two commercially available toothpastes (A and B) with 1000 ppm fluoride each for their children as they would normally do at home. The toothpaste amounts were weighed, and as reference, the weight of an 'optimal' grain of rice-size amount of each toothpaste was used.

RESULTS

61 parents dosed a mean of 0.263 ± 0.172 g toothpaste A and 0.281 ± 0.145 g toothpaste B. The parents' mean doses were 5.9 times higher for toothpaste A and 7.2 times higher for toothpaste B than an 'optimal' grain of rice-size amount (the reference dose as recommended). The difference between parent's and reference dose was statistically significant (p < 0.001). Moreover, 39.3% of parents were not aware about conditions of use and warnings that have to be printed on the package of fluoride toothpastes.

CONCLUSION

In this study, parents significantly overdosed the toothpaste for their children. To avoid fluoride intake from toothpaste, parents can choose fluoride-free alternatives for the oral care of their infants and toddlers.

Methodological quality of evidence-based clinical practice guidelines in cariology

OBJECTIVE

The present study aimed to appraise the methodological quality of evidence-based Clinical Practice Guidelines (CPGs) in the cariology field.

MATERIALS AND METHODS

A systematic search on electronic databases (MEDLINE/Pubmed, EMBASE, DARE and Epistemonikos), websites, and guideline organizations were undertaken. Evidence-based CPGs including at least one recommendation for clinical prevention and/or management of dental caries, developed for any clinical setting, were included. The quality of each guideline was evaluated using the AGREE II tool. Descriptive analysis was performed and the average overall score for each domain was calculated.

RESULTS

Thirty-two guidelines were included. Most of the CPGs achieved higher scores for the domains of clarity of presentation (66.7%, 95% IC 37.3-52.2) and scope and purpose (59.6%, 95% IC 53.7-65.5) domains; and lower scores for editorial independence (46.1%, 95% IC 37.8-55.7) and applicability domain (44.7%, 95% IC 37-55.3). The reviewers assessed 12 CPGs (37.5%) as recommended for use, 15 (46.9%) recommended with modifications, and 5 (15.6%) as not recommended.

CONCLUSION

The overall methodological quality of evidence-based CPGs in the cariology field is moderate, and there is a need for improvements in reporting related to most domains. The poorest reporting was found in the description of the domains' applicability of its recommendations and editorial independence.

CLINICAL RELEVANCE

Clinical Practice Guidelines provide guidance to patients, healthcare professionals, and stakeholders. The quality of these documents is essential for establishing trust in their recommendations.

Update of the molar incisor hypomineralization: Würzburg concept

PURPOSE

Molar incisor hypomineralization (MIH) is playing an increasingly important role in dental practice. MIH is defined as hypomineralization of systemic origin of one to four permanent first molars, often associated with affected incisors. Affected teeth are more susceptible to caries and post-eruptive enamel loss and should be diagnosed and treated as early as possible. In 2016, the Würzburg concept was developed for German-speaking countries including a classification index-the MIH Treatment Need Index (MIH-TNI)-and a treatment plan based on it for the use in daily practice. In the meantime, the concept has also gained international recognition. The aim of this paper is to update part 2 of the Würzburg concept, the treatment plan, as knowledge about MIH has increased and the disease has been studied more extensively in the last years. Other treatment approaches are now available and therefore need to be included in the concept. Although, the evidence of the different treatment options is still weak, practitioners need guidance in their daily practice.

METHODS

The authors reviewed the available literature, including clinical and laboratory studies and published guidelines.

RESULTS

The updated version of the Würzburg concept includes additional non-invasive strategies and temporary therapy options, as well as treatment approaches for incisors. It therefore covers currently available treatment modalities for MIH-affected teeth, ranging from prophylaxis, non-invasive treatment to restorative approaches and possibly even extraction.

CONCLUSIONS

This is intended to help guide the practitioner and will need to be further validated by clinical trials.

Toothpaste use in Peruvian children during COVID-19 pandemic: results from a National Demographic and Health Survey

PURPOSE

To determine the impact of COVID-19 pandemic on use of toothpaste in Peruvian children.

METHODS

A national database of Peruvian children from 0 to 11 years old was used to develop a cross-sectional study, with a final sample of 51, 013 subjects. Data were obtained of results of the Demographic and Family Health Survey (ENDES); the questionnaire was self-reported. The use of toothpaste and fluoride concentration in toothpaste were dependent variables, and for the independent variable, the year was considered; in addition, other covariates were included. The statistical analyses applied were descriptive, bivariate, and multivariate tests.

RESULTS

Use of toothpaste was 98.99% (n = 50,134), while fluoride toothpaste with < 1000 ppm was used by 77.29% (n = 27,366). For bivariate analysis, use of toothpaste was associated with place and area of residence, altitude, natural region, and age; for use of fluoride toothpaste with minimum 1000 ppm, there was an association with place and area of residence, natural region, wealth index, and age. In a multivariate manner, year only presented a positive association with use of fluoride toothpaste < 1000 ppm (RPa:1.04; 95%CI 1.01-1.07).

CONCLUSIONS

Year 2020 of COVID-19 pandemic had a positive impact on the use of < 1000 ppm fluoride toothpaste in Peruvian children.

Prevalence and socio-behavioral determinants of early childhood caries in children 1-5- year- old in Iran

AIM

According to the World Health Organization (WHO), early childhood caries (ECC) is still considered a major global health problem despite the general improvement in oral health practice. This study aimed to assess ECC's prevalence, severity, and key social and behavioral determinants in Iranian children 1-5- years of age.

METHOD

This cross-sectional study recruited Iranian 1-5-year-olds with a three-stage stratified clustered sampling method. After providing consent, parents were interviewed using a validated questionnaire, including questions on child characteristics and behavioral factors. Each child underwent a dental examination by one of four trained and calibrated dentists. Associations between key covariates of interest and primary outcome measures were assessed by multivariable logistic regression modeling and multivariate generalized negative binomial regression modeling after weightings were applied. Statistical analysis was performed using SPSS V25 and Stata V14.2 software packages. A p-value ≤ 0.05 was considered significant.

RESULTS

The mean age of 909 participants was 41.1±1.2 months, 48.6% were male, and 38.1% lived in rural areas. The overall prevalence of ECC was 53.2% and mean dmft score was 2.7± 0.3. Key determinants associated with ECC included living rurally (p = 0.009, OR = 2.13), consuming sweet drinks, sugary snacks, or both [p-value = 0.02 (OR = 2.53), and p-value<0.001 (OR = 4.96), respectively], and visible plaque (p<0.001, OR = 3.41). Covariates associated with dmft scores included residing in rural regions (p = 0.02, IRR = 1.31), having both sugary snacks and sweet drinks (p = 0.02, IRR = 1.85) compared to those had none, and visible dental plaque (p<0.001, IRR = 2.06).

CONCLUSIONS

The prevalence of dental caries in children is high in Iran. The increase of ECC prevalence and severity from toddlers to preschoolers emphasizes on the critical importance of early interventions in toddlers. Improving access to care for rural children is essential along with the need to change dietary and self-care behaviors through multilevel efforts.

Tooth brushing with fluoridated toothpaste and associated factors among Chinese adolescents: a nationwide cross-sectional study

BACKGROUND

Tooth brushing with fluoridated toothpaste has become the most important way to provide the anti-caries effect of fluoride around the world. China has promoted the use of fluoridated toothpaste since 1989. However, there are few studies on the national profile of use of fluoridated toothpaste and related factors in Chinese adolescents. We carried out this study to investigate oral hygiene behaviours, especially the status of tooth brushing with fluoridated toothpaste and its correlates among adolescents, based on data from the latest Nation Oral Health Survey in mainland China.

METHODS

This cross-sectional study recruited 118,601 participants aged 12-15 years using multistage stratified sampling. Questionnaires were completed by students at school. Data employed in analyses were extracted from the questionnaire, including information on tooth brushing, fluoridated toothpaste, dental floss, sociodemographic factors, fluoride knowledge and attitude towards regular dental check-ups. A binary logistic regression was performed to compute the odds ratios (OR). Tooth brushing twice daily with fluoridated toothpaste was the dependent variable. Sociodemographic factors, fluoride knowledge, attitude towards regular dental check-ups, dental visit experience and perceived oral health were the independent variables. P < 0.05 was considered statistically significant.

RESULTS

A total of 32.6% of participants brushed their teeth twice daily, 7.4% used fluoridated toothpaste, and 3.9% cleaned their teeth twice daily with fluoridated toothpaste. The logistic regression showed the probability of twice-a-day tooth brushing with fluoridated toothpaste was higher among these groups: females (OR: 1.141; 95%CI: 1.072-1.214), 15-year-olds (OR: 1.786; 95%CI: 1.634-1.952), from urban areas (OR: 1.389; 95%CI: 1.288-1.497), without siblings (OR: 1.351; 95%CI: 1.259-1.450), with an educated father (OR: 1. 605; 95%CI: 1.442-1.788) and mother (OR: 1.706; 95%CI: 1.530-1.903), having dental visit experiences (OR: 1.702; 95%CI: 1.589-1.823), rating one's oral health as good (OR: 2.341; 95%CI: 2.083-2.631), having fluoride knowledge (OR: 4.345; 95%CI: 4.034-4.678) and having a positive attitude towards regular dental check-ups (OR: 1.589; 95%CI: 1.460-1.729).

CONCLUSIONS

The oral hygiene behaviours of Chinese adolescents were undesirable. Twice daily tooth brushing with fluoridated toothpaste was significantly associated with sociodemographic factors, fluoride knowledge, and attitudes towards regular dental check-ups.

Amount of toothpaste used by dental students

PURPOSE

This study analyzed associations of cumulative learning, demographic characteristics, fluoride content, and toothbrush head size with the amount of toothpaste used by dental students.

METHODS

Students in the third and fifth year of dental school were recruited. Each participant was asked to dispense three toothpastes (pediatric, regular fluoride, and high fluoride) on five toothbrushes (rotation-oscillation, sonic, manual pediatric, and two manual adult toothbrushes). The length and weight of the toothpaste dispensed were recorded. The data were evaluated by nonparametric correlation analysis (P < 0.05).

RESULTS

Eighty-one students (third year = 42; fifth year = 39; mean age: 26.2 ± 5.3 years) participated in the study. More toothpaste was dispensed by third-year students than by fifth-year students (weight: P = 0.014; length: P = 0.037). Men dispensed more toothpaste than did women (weight: P < 0.001; length: P = 0.042). Participants with higher educational attainment dispensed less toothpaste (weight: P < 0.001; length: P < 0.001). The type of toothbrush was associated with the weight of toothpaste dispensed (P < 0.001). Toothbrush head size was inversely associated with the length of toothpaste dispensed (P < 0.001).

CONCLUSION

The amount of toothpaste used by dental students was associated with cumulative learning, educational attainment, sex, and toothbrush head size but not with the fluoride content of the toothpaste.

A Short Review of the Toxicity of Dentifrices-Zebrafish Model as a Useful Tool in Ecotoxicological Studies

This review aims to summarize the literature data regarding the effects of different toothpaste compounds in the zebrafish model. Danio rerio provides an insight into the mechanisms of the ecotoxicity of chemicals as well as an assessment of their fate in the environment to determine long-term environmental impact. The regular use of adequate toothpaste with safe active ingredients possessing anti-bacterial, anti-inflammatory, anti-oxidant, and regenerative properties is one of the most effective strategies for oral healthcare. In addition to water, a typical toothpaste consists of a variety of components, among which three are of predominant importance, i.e., abrasive substances, fluoride, and detergents. These ingredients provide healthy teeth, but their environmental impact on living organisms are often not well-known. Each of them can influence a higher level of organization: subcellular, cellular, tissue, organ, individual, and population. Therefore, it is very important that the properties of a chemical are detected before it is released into the environment to minimize damage. An important part of a chemical risk assessment is the estimation of the ecotoxicity of a compound. The zebrafish model has unique advantages in environmental ecotoxicity research and has been used to study vertebrate developmental biology. Among others, the advantages of this model include its external, visually accessible development, which allows for providing many experimental manipulations. The zebrafish has a significant genetic similarity with other vertebrates. Nevertheless, translating findings from zebrafish studies to human risk assessment requires careful consideration of these differences.

Efficient Removal of Dental Plaque Biofilm from Training Typodont Teeth via Water Flosser

Plaque biofilms play critical roles in the development of dental caries. Mechanical plaque control methods are considered to be most effective for plaque removal, such as brushing teeth or using flosser. Recently, water flosser has been paid much attention. Here, we tested the ability of a water flosser to remove the adhered sucrose and the dental plaque biofilms formed by Streptococcus mutans, Streptococcus sanguinis, and Actinobacillus viscosus. We found that the residual sucrose concentration was 3.54 mg/mL in the control group, 1.75 mg/mL in the syringe group (simulating the ordinary mouthwash), and 0 mg/mL in water flosser group. In addition, the residual bacterial concentration was 3.6 × 108 CFU/mL in the control group, 1.6 × 107 CFU/mL in the syringe group, and only 5.5 × 105 CFU/mL in the water flosser group. In summary, water flosser is effective for cleaning the teeth, which may have significant potential in preventing dental caries and maintaining oral health.

Carious status and socio-behavioral risk factors among 12 year-old children in South-Central region in Romania

BACKGROUND

Regular screenings at children population level are necessary in order to assess communities' need for education, prevention, as well as early detection and intervention programs The study aims to assess dental caries experience and oral health-related behaviors among Romania children from the South and Central region.

METHODS

The cross-sectional study conducted in 2019-2020 is part of the national survey "Romanian Oral Health Survey", under the endorsement of the World Health Organization (WHO). The stratified, randomized and representative sample included 98 children of 12 years of age. The assessment included a clinical examination, using International Caries Detection and Assessment System (ICDAS) and the Oral Health Questionnaire for Children recommended by the World Health Organization.

RESULTS

Results revealed that the frequency of caries-free children among 12 year-olds was 36.7% and the mean DMFT was 2.89. Regarding the oral health-related habits, 38.8% of children brushed twice daily; the consumption of sugary foods multiple times per day has been frequently met and 11.2% at the age of 12 never visited the dental office.

CONCLUSIONS

The findings revealed that caries prevalence was high and behaviors negatively influence oral health. The presented data are of utmost importance for Romanian policy makers to promote oral health education among children, to support consistent preventive oral health campaigns and to stimulate dental attendance, irrespective of children' living areas or gender.

Oral Health of Rural Cameroonian Children: A Pilot Study in Bamendou

Access to dental care in Cameroon is a public health issue, particularly for children living in rural areas. Given the lack of recent data, the investigation of children's oral health along with their oral hygiene behavior, needs in terms of care, and access to oral hygiene materials were investigated. This cross-sectional pilot study was conducted in Bamendou, Western Region of Cameroon. The study population included 265 children aged 3-18 years who completed a questionnaire about their oral hygiene practices. A clinical examination assessed dental caries, calculus, gingivitis, and oral hygiene. The Chi-squared test was used to identify potential factors influencing caries prevalence rates (significance threshold: p < 0.05). Among the 265 children (females: 41.5%, mean age 9.3 years), caries prevalence (ICDAS ≥ 2) was 78.5% and significantly increased with age: 62.2% (3-6 years), 80.9% (7-11 years) and 84.1% (12-18 years, p = 0.01). Virtually no children (95.1%) had ever visited a dentist. While only 23.4% of children brushed their teeth at least twice a day, 14% worryingly reported the use of products other than toothpaste (ash, soap, salt, or bicarbonate) and 13.6% no brushing product. The present study revealed a high prevalence of dental caries in this population and inadequate toothbrushing habits, which highlights the need for preventive oral health education and intervention to address these issues.

Improving Oral Health with Fluoride-Free Calcium-Phosphate-Based Biomimetic Toothpastes: An Update of the Clinical Evidence

As the demand for clinically effective fluoride-free oral care products for consumers increases, it is important to document which types of toothpastes have been shown in clinical studies to be effective in improving oral health. In this review, we included different indications, i.e., caries prevention, improving periodontal health, reducing dentin hypersensitivity, protecting against dental erosion, and safely improving tooth whitening in defining what constitutes improvement in oral health. While there are several professional and consumer fluoride-containing formulations fortified with calcium-phosphate-based ingredients, this review focuses on fluoride-free toothpastes containing biomimetic calcium-phosphate-based molecules as the primary active ingredients. Several databases were searched, and only clinical trials in human subjects were included; in vitro and animal studies were excluded. There were 62 oral health clinical trials on biomimetic hydroxyapatite (HAP), 57 on casein phosphopeptide-amorphous calcium phosphate (CPP-ACP), 26 on calcium sodium phosphosilicate (CSPS, or so called Bioglass), and 2 on β-tricalcium phosphate (β-TCP). HAP formulations were tested the most in clinical trials for benefits in preventing caries, dentin hypersensitivity, improving periodontal health, and tooth whitening. Based on the current clinical evidence to date, fluoride-free HAP toothpaste formulations are the most versatile of the calcium phosphate active ingredients in toothpastes for improving oral health.

Oral health profile and periodontal diseases awareness and knowledge among the jordanian population: a cross-sectional study

OBJECTIVE

To explore the oral health profile and periodontal diseases awareness and knowledge among the Jordanian population. In addition, we aimed to identify predictors of good knowledge of periodontal diseases.

METHOD

This was an online cross-sectional survey study that was conducted in Jordan between January and May 2022. A total of 13 item from the world health organisation (WHO) oral health questionnaire for adults were used to examine the oral health profile of our study participants. In addition, a previously developed questionnaire by Abdulbaqi et al. were adapted and used to examine participants' knowledge about periodontal diseases. Binary logistic regression analysis was used to identify predictors of better knowledge of periodontal diseases.

RESULTS

This study involved 1,099 participants in total. More than half of them (61.1%) claimed that throughout the previous 12 months, they had experienced pain or discomfort in their mouths or teeth. Nearly half of the participants said their teeth and gums were in good or very good condition. 70.7% said they brush their teeth once or more per day. The vast majority of them (93.0%) claimed to brush their teeth using toothpaste that contained 61.9% fluoride. The most frequent cited cause for dental visits was pain or difficulty with teeth, gums, or mouth (36.3%), according to almost one-third of study participants who said they had visited a dentist during the previous six months. The most commonly reported problems that occurs frequently due to the state of the participants' teeth or mouth were avoiding smiling because of teeth, feeling embarrassed due to appearance of teeth, and having difficulty in biting foods with 11.0%, 10.2%, and 9.0%, respectively. Tea with sugar (16.5%) was the most frequently reported beverage as being consumed frequently on a daily basis. The most popular tobacco product to be smoked often on a daily basis was cigarettes (21.6%). For periodontitis knowledge questions, the percentage of accurate responses ranged from 32.3 to 55.8%. The majority of participants (55.8%) were able to recognize that poor oral hygiene is one of the most frequent causes of malodor, whereas the least number of participants (32.3%) were able to recognize that improper teeth brushing is a frequent cause of gingival recession.

CONCLUSION

The average degree of periodontitis knowledge among Jordanians was moderate. Along with it, there were modest oral hygiene practices. In order to prevent further oral complications that have a detrimental influence on patients' quality of life, educational campaigns are required to increase public awareness of knowledge and practices in terms of proper oral hygiene and periodontitis.

Caries-preventing effect of a hydroxyapatite-toothpaste in adults: a 18-month double-blinded randomized clinical trial

Background

Dental caries is a worldwide challenge for public health. The aim of this 18-month double-blinded, randomized, clinical trial was to compare the caries-preventing effect of a fluoride-free, hydroxyapatite toothpaste (test) and a toothpaste with sodium fluoride (1450 ppm fluoride; positive control) in adults.

Methods

The primary endpoint was the percentage of subjects showing no increase in overall Decayed Missing Filled Surfaces (DMFS) index. The study was designed as non-inferiority trial. Non-inferiority was claimed if the upper limit of the exact one-sided 95% confidence interval for the difference of the primary endpoint DMFS between test and control toothpaste was less than the predefined margin of non-inferiority (Δ ≤ 20%).

Results

In total, 189 adults were included in the intention-to-treat (ITT) analysis; 171 subjects finished the study per protocol (PP). According to the PP analysis, no increase in DMFS index was observed in 89.3% of subjects of the hydroxyapatite group and 87.4% of the subjects of the fluoride group. The hydroxyapatite toothpaste was not statistically inferior to a fluoride toothpaste with regard to the primary endpoint.

Conclusion

Hydroxyapatite was proven to be a safe and efficient anticaries agent in oral care.

Clinical trial registration

NCT04756557.

A Systematic Review of Clinical Practice Guidelines for Caries Prevention following the AGREE II Checklist

Untreated oral diseases are detrimental to overall well-being and quality of life and are in close relationship with social and economic consequences. The presence of strong evidence for caries primary and secondary prevention is a compulsory tool for the development of clinical practice guidelines (CPGs). This paper was aimed to assess systematically the importance of clinical practice guidelines in caries prevention management considering both the adult and pediatric populations and evaluate them using the Appraisal of Guidelines for Research and Evaluation (AGREE II) Checklist. Records were extracted from EMBASE, SCOPUS, PubMed/Medline and seven other relevant guideline databases between 6 January and 14 February 2023. Two reviewers independently conducted the appraisal using the web-based platform My AGREE PLUS. Twenty-one guidelines/papers met the inclusion criteria and were reviewed. Eight CPGs included both primary and secondary prevention interventions, whereas thirteen presented a single preventive model. Overall, 12 guidelines were published in the USA. The mean AGREE II scores ranged from 35.4% to 84.3%. Of the total twenty-one included guidelines, twelve were classified as "Recommended", ranging from 56.3% to 84.3%, the others were described as "Recommended with modification", ranging from 35.4% to 68.9%. From the AGREE II analysis carried out, the CPGs included in this survey adopted a punctual methodological rigor but lacked applicative power. The present survey showed that the public, as the primary beneficiary, played a limited role in the development of the twenty-one CPGs. Hence, methodological improvement can better support high-quality CPG development in the future.

Early childhood caries: Detection, prevention, and referral. A questionnaire study of general medical practitioners and pediatricians in the south of France

INTRODUCTION

Early childhood caries (ECC) is an illness defined as the presence of one or more decayed, missing after caries, or filled tooth surfaces in any primary tooth in a child under the age of 6 years. It has a negative impact on the physical and the psychological development of children. General medical practitioners (GPs) and pediatricians, the first professionals involved in the follow-up of young children, are on the frontline of detecting and referring patients with caries or individual high-risk of carious lesions. The aims of this study were (1) to assess the current state of knowledge of pediatricians and GPs in the south of France regarding ECC detection and prevention, and (2) to understand whether there are difficulties in referring young patients for the early detection of carious lesions.

METHODS

A semi-structured questionnaire was circulated to GPs and pediatricians working in the Provence-Alpes-Côte d'Azur region (France). The questionnaire was divided into three parts related to the characteristics of the participants, to the current skill and knowledge of practitioners in detecting ECC (using clinical vignettes) and advising preventive measures, and to the dental examination and any difficulties in referring patients.

RESULTS

There were 97 participants in the study. Many oral hygiene measures were known but only just over half of the dietary risk factors were recognized. Participants seemed to be involved in detecting ECC, the majority very often examined teeth during their consultations. Practitioners recognized a carious lesion in only one of two cases. The lack of knowledge of the recommended age for the first consultation could be a barrier in referring patients to a dentist, for which pain remains the main reason for referral.

CONCLUSION

GPs and pediatricians should play a key role in the detection and prevention of ECC. Participants showed great interest in the topic of oral health. For better management, it would be beneficial to provide training resources with quick and efficient access to information.

The effectiveness of topical fluoride agents on preventing development of approximal caries in primary teeth: a randomized clinical trial

BACKGROUND

This 18-month randomized clinical trial aimed to compare the effectiveness of two topical fluoride applications versus placebo control on preventing development of approximal caries in primary teeth.

METHODS

Preschool children were recruited if they had at least one initial approximal carious lesion at the distal surface of the canines, both approximal surfaces of the first molars, or the mesial surface of the second molars assessed from bitewing radiographs. The participants were randomly allocated into 3 intervention groups: Group 1 (placebo control), Group 2 (5% sodium fluoride [NaF] varnish), and Group 3 (38% silver diamine fluoride [SDF]). All agents were applied semiannually. Two calibrated examiners evaluated the caries development from bitewing radiographs. Caries development was recorded when the baseline sound surface or initial approximal carious lesion surface developed dentin caries (beyond the outer one-third of dentine) at the follow-up examination. The intention-to-treat approach was adopted. The Chi-square test was used to analyze the effectiveness of topical fluoride agents in preventing approximal caries development and the effect of other variables. The multi-level logistic regression analysis was performed to assess the relative effectiveness of topical fluoride agents in preventing approximal caries development at the 18-month follow-up.

RESULTS

At baseline, 190 participants with 2,685 sound or initial carries at the approximal surfaces were recruited. No differences in participant demographic backgrounds, oral health related habits, or caries experience were observed among the 3 groups (P > 0.05). After 18 months, 155 (82%) participants remained in the study. The rates of developing approximal caries in Groups 1, 2, and 3 were 24.1%, 17.1%, and 27.2%, respectively (P < 0.001, χ² test). After adjusting for confounding factors and clustering effect, the multilevel logistic regression analysis showed no differences in caries development rates between the 3 groups (P > 0.05). Tooth type and the extent of a carious lesion at baseline were the significant factors for caries development.

CONCLUSION

At 18-month follow-up, after adjusting for confounding factors and clustering effect, there were no statistically significant differences in preventing of approximal caries development between the semiannual application of 5%NaF, 38%SDF, or placebo.

TRIAL REGISTRATION

The study was registered in the Thai Clinical Trials Registry under the number TCTR20190315003 on 15/03/2019.

Digital Application for Promoting Evidence-Based Children's Oral Health to Control Early Childhood Caries: Randomized Control Trial on Parental Acceptance and Efficacy

BACKGROUND

Early childhood caries (ECC) remains a major global health problem. Various measures to prevent it have been implemented in the past, including those using digital applications.

AIM

To evaluate the acceptance and efficacy of a digital application (FU-APP) based on evidence-based caries control recommendations for parents of children aged 6-72 months.

METHODS

Part 1, prospective questionnaire-based survey to test FU-APP (usage, acceptance, content information, usefulness, and satisfaction) filled out by parents (n = 22); Part 2, two-armed (test n = 20; control n = 23) care-based, randomized controlled trial, where the test arm received instructions verbally and via FU-APP, and the control arm received them only verbally. At baseline and follow-up (4 weeks), intraoral clinical indices (plaque index-API and caries-dmft) were recorded.

RESULTS

FU-APP was considered by parents to be a suitable tool for gaining knowledge about oral health practices for their children (all criteria >86%). No differences in the dmft levels were expected. However, API was significantly better at the follow-up in the test-arm (p = 0.01), with no differences in the control-arm (p = 0.72).

CONCLUSION

A digital application can serve as an innovative tool to promote evidence-based oral hygiene recommendations among parents of children to control ECC. Its long-term usability and functionality should be tested.

Drinking hot beverages from paper cups: Lifetime intake of microplastics

Microplastics (MPs) have been found in many packaged food products such as salt, tea bags, milk, and fish. In a previous study by this group, MPs were found to leach into hot water from the plastic lining of disposable paper cups. No studies were found in the literature quantifying health risks or lifetime intake of MPs. At present, it is not possible to quantify health risks due to MPs because dose-response and toxicity assessments are not available. Therefore, the objective of the current study was to assess the intake of MPs and associated contaminants like fluoride that are released into these hot beverages. MPs in the previous study were quantified in terms of particle counts only and a simple method was adopted in the present study to convert the microplastics count into its respective mass. Chronic daily intake (CDI) and lifetime intake (LTI) of MPs through the ingestion pathway were calculated. CDI and Hazard Quotient (HQ) due to fluoride ingestion were also estimated following USEPA guidelines. Monte Carlo (MC) simulations were used to account for the variability in input variables such as concentration of MPs, body weight, averaging time, exposure duration, exposure frequency and ingestion rate to evaluate the impact on CDI and LTI values. The CDI was used to estimate the LTI of MPs and HQ for fluoride ingestion. MC simulations with 100,000 iterations resulted in an average CDI of 0.03 ± 0.025 mg of microplastic per kg of body weight per day and 7.04 ± 8.8 μg fluoride per kg body weight per day. This study takes us one step closer to estimating the human health risk due to the ingestion of microplastics and other contaminants through food items.

Bioactive Materials for Caries Management: A Literature Review

Researchers have developed novel bioactive materials for caries management. Many clinicians also favour these materials, which fit their contemporary practice philosophy of using the medical model of caries management and minimally invasive dentistry. Although there is no consensus on the definition of bioactive materials, bioactive materials in cariology are generally considered to be those that can form hydroxyapatite crystals on the tooth surface. Common bioactive materials include fluoride-based materials, calcium- and phosphate-based materials, graphene-based materials, metal and metal-oxide nanomaterials and peptide-based materials. Silver diamine fluoride (SDF) is a fluoride-based material containing silver; silver is antibacterial and fluoride promotes remineralisation. Casein phosphopeptide-amorphous calcium phosphate is a calcium- and phosphate-based material that can be added to toothpaste and chewing gum for caries prevention. Researchers use graphene-based materials and metal or metal-oxide nanomaterials as anticaries agents. Graphene-based materials, such as graphene oxide-silver, have antibacterial and mineralising properties. Metal and metal-oxide nanomaterials, such as silver and copper oxide, are antimicrobial. Incorporating mineralising materials could introduce remineralising properties to metallic nanoparticles. Researchers have also developed antimicrobial peptides with mineralising properties for caries prevention. The purpose of this literature review is to provide an overview of current bioactive materials for caries management.

The Activity of Calcium Glycerophosphate and Fluoride against Cariogenic Biofilms of Streptococcus mutans and Candida albicans Formed In Vitro

This study evaluated the effects of calcium glycerophosphate (CaGP), with or without fluoride (F), on dual-species biofilms of Streptococcus mutans and Candida albicans. The biofilms were treated three times with 0.125, 0.25, and 0.5% CaGP solutions, with or without 500 ppm F (NaF). Additionally, 500 and 1100 ppm F-solutions and artificial saliva served as controls. After the final treatment, the microbial viability and biofilm structure, metabolic activity, total biomass production, and the composition of the extracellular matrix composition were analyzed. Regardless of the presence of F, 0.25 and 0.5% CaGP promoted a higher biomass production and metabolic activity increase than the controls (p < 0.05). F-free CaGP solutions reduced bacterial cell population significantly more than the 500 ppm F group or the negative control (p < 0.05). All the groups reduced the proteins, and 0.5% CaGP combined with F led to the highest reduction in the carbohydrate and nucleic acids content of the extracellular matrix (p < 0.05). It can be concluded that CaGP alone affected the number of bacterial cells and, when combined with F, reduced its production of biomass, metabolic activity, and the expression of the extracellular matrix components.

Dental Implants and Implant Coatings: A Focus on Their Toxicity and Safety

Dental implants are medical devices that are surgically inserted into the patient's jawbone by an orthodontist to act as roots of missing teeth. After the implantation, the maxilla or mandible integrates with the surface of the dental implant. This process, called "osseointegration," is an important period to ensure the long-term use of dental implants and prevent implant failures. Metal implants are the most used implant materials. However, they have disadvantages such as corrosion, metal ion release from metal implant surfaces and associated toxicity. To avoid these adverse effects and improve osseointegration, alternative dental implant materials such as ceramics, polymers, composites, and novel surface modification technologies have been developed. The safety of these materials are also of concern for toxicologists. This review will give general information about dental implant materials, osseointegration and successful implantation process. Moreover, we will focus on the new surface coatings materials for of dental implants and their toxicity and safety concerns will be discussed.

Diarylureas: New Promising Small Molecules against Streptococcus mutans for the Treatment of Dental Caries

Dental caries is a biofilm-mediated disease that represents a worldwide oral health issue. Streptococcus mutans has been ascertained as the main cariogenic pathogen responsible for human dental caries, with a high ability to form biofilms, regulated by the quorum sensing. Diarylureas represent a class of organic compounds that show numerous biological activities, including the antimicrobial one. Two small molecules belonging to this class, specifically to diphenylureas, BPU (1,3-bis[3,5-bis(trifluoromethyl)phenyl]urea) and DMTU (1,3-di-m-tolyl-urea), showed interesting results in studies regarding the antimicrobial activity against the cariogenic bacterium S. mutans. Since there are not many antimicrobials used for the prevention and treatment of caries, further studies on these two interesting compounds and other diarylureas against S. mutans may be useful to design new effective agents for the treatment of caries with generally low cytotoxicity.

Oral health-related quality of life in portuguese pre-school children: a cross-sectional study

PURPOSE

To study Oral Health related Quality of Life (OHRQoL) of pre-school children and its associated factors.

METHODS

Cross-sectional study with sample data collected through an on-line questionnaire to a non-probabilistic sample. The questionnaire included the Portuguese version of the Early Childhood Oral Health Impact Scale (ECOHIS) and questions about sociodemographic characteristics, oral health behaviours, and reported oral health of the child. Data analyses included descriptive statistics, Mann-Whitney and Kruskal-Wallis tests and Linear regression (α = 0.05).

RESULTS

The sample consisted of 1475 parents of pre-school children (3-5 years-old), residing in Portugal. The mean ECOHIS total score was 1.5 (sd = 3.4). In the bivariate analysis the child's age, starting toothbrushing after one year of age, frequent intake of sugary food and drinks, previous appointment with an oral health professional, all reported of oral health problems, and a negative perception of oral health were negatively associated with OHRQoL (p < 0,05). In the regression model the factors that most contributed to a worse quality of life were dental caries and abscess, contributing to an ECOHIS average increase of 2.56 and 3.34, respectively.

CONCLUSIONS

The studied population presented a good OHRQoL, with the item related to pain being the most relevant for the ECOHIS score. Worst OHRQoL was found in older children, whose parents negatively rated the children's oral health and with reported dental caries, trauma, and abscess.

Silver diamine fluoride therapy for dental care

Silver diamine fluoride (SDF) was developed in Japan in the 1960s. It is used to control early childhood caries, arrest root caries, prevent fissure caries and secondary caries, desensitise hypersensitive teeth, remineralise hypomineralised teeth, prevent dental erosion, detect carious tissue during excavation and manage infected root canals. SDF is commonly available as a 38% solution containing 255,000 ppm silver and 44,800 ppm fluoride ions. Silver is an antimicrobial and inhibits cariogenic biofilm. Fluoride promotes remineralisation and inhibits the demineralisation of teeth. SDF also inactivates proteolytic peptidases and inhibits dentine collagen degradation. It arrests caries without affecting dental pulp or causing dental fluorosis. Indirect pulp capping with SDF causes no or mild inflammatory pulpal response. However, direct application of SDF to dental pulp causes pulp necrosis. Furthermore, SDF stains carious lesions black. Patients must be well informed before SDF treatment. SDF therapy is simple, painless, non-invasive, inexpensive, and requires a simple armamentarium and minimal support. Both clinicians and patients generally accept it well. In 2021, the World Health Organization included SDF as an essential medicine that is effective and safe for patients. Moreover, it can be used for caries control during the COVID-19 pandemic because it is non-aerosol-generating and has a low risk of cross-infection.

Future Perspectives in Pediatric Dentistry: Where are We Now and where are We Heading?

Oral diseases in children are still a major public health problem that can negatively impact parents and their children's quality of life. Even though oral diseases are largely preventable, initial signs of them can be detected in the 1st year of life, and its severity might increase with time if no preventive measures are taken. Based on this, we aim to discuss "where is pediatric dentistry now?" and "where is pediatric dentistry heading?" Early life oral health conditions are a good predictor of oral health status in adolescence, adulthood, and elderly people. A healthy childhood provides the foundation and opportunities for life; therefore, pediatric dentists have the unique opportunity to identify the presence of unhealthy habits in the 1st year of life and educate the parents and family members to change them for life. If all educational and preventive strategies fail or are not put into practice, the child might present oral health problems, such as dental caries, erosive tooth wear (ETW), hypomineralization, and malocclusion, that could have a great impact on other stages of life. At the moment, in pediatric dentistry, there are many alternatives to prevent and treat these oral health problems. However, if prevention fails, minimally invasive approaches, and new dental materials and technologies have been developed recently and will be important tools available in the near future in order to enhance children's oral health.

How to cite this article

Rodrigues JA, Olegario I, Assunção CM, et al. Future Perspectives in Pediatric Dentistry: Where are We Now and where are We Heading? Int J Clin Pediatr Dent 2022;15(6):793-797.

Fluoride Intake and Salivary Fluoride Retention after Using High-Fluoride Toothpaste Followed by Post-Brushing Water Rinsing and Conventional (1400-1450 ppm) Fluoride Toothpastes Used without Rinsing

This study aimed to compare the fluoride intake and salivary fluoride levels after brushing with conventional (1400-1450 ppm) fluoride toothpaste containing different fluoride agents: amine fluoride (AmF), sodium fluoride (NaF), sodium monofluorophosphate (SMFP), potassium fluoride (KF), and a high-fluoride (5000 ppm) toothpaste containing NaF. Fourteen volunteers took part in the study. They were instructed to brush and spit without rinsing after using conventional toothpaste or brush and rinse with water after using a high-fluoride toothpaste. Fluoride concentrations were determined using ion-selective fluoride (09-37 type) in the saliva samples before and after procedures. Fluoride intake was estimated based on fluoride recovered after brushing. Additionally, the amount of fluoride present in the oral fluids and lost during the rapid clearance phase after toothbrushing was calculated based on salivary fluoride levels and saliva flow immediately after brushing. Salivary fluoride after using high-fluoride toothpaste was significantly higher than those observed after conventional products. Two hours after brushing, salivary fluoride concentrations did not differ significantly from baseline values (p > 0.05) unless a high-fluoride product was used. Results indicate that by refraining from rinsing after brushing with conventional toothpaste, we cannot obtain fluoride retention in saliva as with high-fluoride toothpaste. Fluoride ingestion was higher after using a high-fluoride product.

Parent-reported toothbrushing behaviour in the Portuguese preschool population

PURPOSE

Study toothbrushing behaviours and associated factors in a Portuguese preschool population.

METHODS

The study population was the parents of children attending Portuguese kindergartens. The data on sociodemographic and toothbrushing behaviours, at home and at school, were collected by an online questionnaire. The data analysis was performed using Chi-square, Fisher, Mann-Whitney and Kruskal-Wallis tests (α = 0.05).

RESULTS

The sample included 711 parents. Most of the children brushed their teeth at home at least twice-a-day (65.3%), with the help of an adult (62.9%). The majority of the children did not brush their teeth at school (71.2%); however, only 9.9% of the parents reported that they don't/wouldn't authorise it. Considering both toothbrushing, at home and at school, 75% of the children brushed their teeth twice-a-day. However, only 7.8% of the children performed all the correct toothbrushing related procedures. Toothbrushing at school was more frequent in private kindergartens (p < 0.001). A higher level of education was associated with non-authorisation of toothbrushing at school (p = 0.019) and with performing the correct toothbrushing related procedures (p = 0.007). Attending an oral health professional appointment was also associated with performing the correct toothbrushing related procedures (p = 0.005).

CONCLUSION

Toothbrushing twice-a-day was frequent in the studied population, however, the percentage of children who brushed at school was low, as well as the percentage of children who performed all the correct toothbrushing related procedures. Toothbrushing at school was more likely in private kindergartens. Performing correct toothbrushing related procedures was more frequent in children who had a previous oral health appointment and whose parents had a higher education level.

Exploring the Relationships between Children's Oral Health and Parents' Oral Health Knowledge, Literacy, Behaviours and Adherence to Recommendations: A Cross-Sectional Survey

Although preventable, early childhood caries (ECC) is a burdening condition in all WHO regions, with Poland being one of the most affected countries in Europe. Effective home-based prevention of ECC is available and recommended by several expert bodies. Therefore, we wanted to determine how well parents were following selected oral health recommendations in preschool children. Additionally, we wanted to determine which socioeconomic factors influenced such practices the most, and how parents' oral health literacy and behaviours affected the oral hygiene and oral health status of their children. A cross-sectional survey involving 2338 parents and caregivers of children from 167 kindergartens was performed. Children's oral hygiene and oral health status were found to be associated with parents' education and economic status. They were also strongly influenced by parental health literacy and behaviours. With respect to recommendations for preschoolers, the lowest adherence was found in the use of fluoride toothpaste and its age-appropriate amount, supervision of toothbrushing, and refraining from eating after last toothbrushing. The improvement in these areas could be achieved thanks to the involvement of health professionals such as gynaecologists, midwives, and primary care personnel in efforts aimed at increasing parents' oral health knowledge and literacy.

What Do Mothers (or Caregivers) Know about Their Children’s Oral Hygiene? An Update of the Current Evidence

Tooth decay remains one of the most common diseases in children, although it is a preventable injury and despite significant advances that has been made in terms of attention and care for oral hygiene. Several studies have shown the association between prevalence of tooth decay in children and parents’ incorrect oral care habits, with a low educational level and a low socioeconomic background. The question that arises concerns the actual oral hygiene knowledge of mothers, fathers, family members or caregivers of young patients; therefore, the aim of this review is to investigate the genesis of gaps in the topic. A literature search was conducted through the Scopus and PubMed search engine and ended in May 2022; only studies from the past 20 years were included. Current evidence suggests that parents and caregivers still have little knowledge about their children’s oral health: there is not enough awareness about the importance of preventing oral diseases, due to poor attention to good oral hygiene but also lack of information from health professionals and institutions. In the future, all the professionals involved in the pregnant woman’s care should increase parents’ knowledge, solve their doubts, collect and compare data in order to design effective intervention programs.

Spanish Paediatricians’ Knowledge, Attitudes and Practices Regarding Oral Health of Children under 6 Years of Age: A Cross-Sectional Study

Background: Early Childhood Caries (ECC) is a prevalent chronic pathology, and it has a negative impact on the oral and general health of the child patient. Aim: To evaluate the knowledge, attitudes and practices of Spanish paediatricians regarding early childhood caries according to the professional’s years of experience. Material and Methods: A cross-sectional questionnaire was conducted by Spanish paediatricians via WhatsApp and e-mails from January to April 2021. Data were analysed using Chi-squared test, Fisher’s exact test and Cramer’s V test. Results: There were a total of 359 participants. Most respondents were women (81.3%) with up to 10 years of professional experience (31.2%) in primary health care and public health. In most cases, participants had an excellent knowledge of primary dentition (90.8%), but they ignored (56%) when the first visit to the dentist should occur. Regarding the aetiological factors of caries, oral hygiene and prevention, a lower rate of knowledge was observed. The majority of participants (80.8%) were not able to identify white spot lesions and enamel defects (76%). They considered that their knowledge in oral health was deficient, highlighting the need to increase their training. Less experienced paediatricians were found to have higher success rates. Conclusions: The level of knowledge and attitudes regarding early childhood caries of the evaluated paediatricians should be improved. Paediatricians had difficulties in identifying early caries lesions and enamel defects. Nevertheless, a higher level of knowledge and positive attitudes towards dental caries has been detected among paediatricians with fewer years of professional experience.

Candida species and selected behavioral factors co-associated with severe early childhood caries: Case-control study

Severe Early Childhood Caries (sECC) is a multifactorial disease associated with the occurrence of specific oral microorganisms and other environmental, behavioral, and genetic factors. This study aimed to construct a multivariable model including the occurrence of Candida spp. and selected behavioral factors (length of breastfeeding, serving sweet beverages and beginning of brushing child’s teeth) to determine their relationships to the occurrence of sECC.

In this case-control study 164 children with sECC and 147 children without dental caries were included. MALDI-TOF MS and multiplex qPCR were used to identify Candida spp. and selected bacteria in dental plaque samples, respectively. A questionnaire on oral hygiene, diet, and children’s health was filled in by the parents.

The constructed multivariable logistic regression model showed an independent influence of the microbial and behavioral factors in sECC etiopathogenesis. The occurrence of C. albicans and C. dubliniensis was associated with higher odds of sECC development (odds ratio, OR: 9.62 and 16.93, respectively), together with breastfeeding of 6 months or less (OR: 2.71), exposure to sweet beverages (OR: 3.77), and starting to brush child’s teeth after the 12^th month of age (OR: 4.10), all statistically significant (p < 0.01).

Considering the high occurrence of C. albicans and C. dubliniensis in dental plaque in children with sECC, we propose them as “keystone pathogens” and risk factors for sECC. The models showed that presence of specific species of Candida in dental plaque may be a better descriptor of sECC than the mentioned behavioral factors.

Influence of the Amount of Toothpaste on Cleaning Efficacy: An In Vitro Study

OBJECTIVES

 The aim of this in vitro study was to test the influence of the amount of toothpaste on enamel cleaning efficacy.

MATERIALS AND METHODS

 The hydrated silica-based test toothpaste (radioactive dentin abrasion: 60.19 ± 1.35) contained all ingredients of a regular fluoride toothpaste. The cleaning efficacy of four different toothpaste amounts (1.00 g, 0.50 g [both "full length of brush"], 0.25 g ["pea-size"], and 0.125 g ["grain of rice-size"]) diluted in 1.00 mL water were each tested for different brushing times (10, 30, 60, 120, 180, and 300 seconds) using a standardized staining model on human molars with a brushing machine. Photographic documentation and colorimetric measurements were conducted, respectively, initially, after staining and after each brushing step. Colorimetric measurements were used to calculate the stain removal (in %).

STATISTICAL ANALYSIS

 Results were analyzed by one-way analysis of variance with post hoc Tukey test and Levene's test for analysis of homogeneity of variance. The level of significance α was set at ≤ 0.05.

RESULTS

 The cleaning efficacy decreased significantly when using smaller toothpaste amounts. Stain removal after 120 seconds brushing time was: 77.4 ± 5.0% (1.00 g toothpaste), 75.7 ± 3.4% (0.50 g toothpaste), 54.1 ± 6.7% (0.25 g toothpaste), and 48.2 ± 7.1% (0.125 g toothpaste), respectively.

CONCLUSION

 In this in vitro study the cleaning efficacy of a medium-abrasive, hydrated silica-based toothpaste was analyzed. Note that 1.00 g toothpaste showed for all brushing times a significantly higher cleaning efficacy than 0.25 g toothpaste and 0.125 g toothpaste.