Four-year study of caries inhibition of intensive Duraphat application in 11-15-year-old children

Cost-effectiveness of caries preventive interventions - a systematic review

OBJECTIVE

The primary purpose of this study was to assess the cost-effectiveness of caries preventive interventions.

MATERIAL AND METHODS

A systematic review was conducted, following the PRISMA Statement. Four electronic databases were searched (final search 16 March 2020). Studies fulfilling the inclusion criteria were independently critically appraised, by two reviewers in parallel. Data from each included study were extracted and tabulated: the analysis used a narrative approach to present the results of the estimated cost-effectiveness.

RESULTS AND CONCLUSIONS

Twenty-six publications fulfilled the inclusion criteria and were of low or moderate risk of bias. Ten publications were economic evaluations, directly based on empirical studies, and the other 16 were modelling studies. Most of the studies concerned interventions for children and the most common were analyses of fluoride varnish and risk-based programs. Some of the studies showed both reduced cost and improved outcomes, but most studies reported that the improved outcome came with an additional cost. The results disclosed several cost-effectiveness evaluations of caries preventive interventions in the literature, but these target primarily children at high risk. There is a scarcity of studies specifically targeting adults and especially the elderly.

Efficacy of S-PRG filler containing varnishes on enamel demineralization prevention

This study evaluated the efficacy of S-PRG vanishes on preventing enamel demineralization. Bovine enamel specimens were obtained, polished and the baseline Knoop microhardness was evaluated. Specimens were stratified into six groups (n = 15), according to the varnish applied: S10—experimental varnish containing 10% of S-PRG fillers, S20—20% of S-PRG fillers, S30—30% of S-PRG fillers; S40—40% of S-PRG fillers; PC (positive control)—5% of NaF; NC (negative control)—no treatment was performed. Half of enamel surfaces were protected to work as a control and varnishes were applied over the unprotected area. A demineralizing pH-cycling was performed, and surface and cross-sectional microhardness were measured. The percentage of microhardness of the treated area was calculated comparing with the untreated area. Statistical analysis was performed by one-way ANOVA and Tukey’s test (p = 5%). All experimental S-PRG varnishes protected against demineralization in relation to no treatment, but S40 was the most effective on the surface. For all depths, S30 and S40 were superior in enamel demineralization prevention than other S-PRG filler concentrations and 5% NaF. It was concluded that S-RPG filler containing varnishes were effective to prevent enamel demineralization. The higher concentrated products were more effective than 5% sodium fluoride on surface demineralization prevention.

Efficacy of S-PRG filler containing varnishes on enamel demineralization prevention

This study evaluated the efficacy of S-PRG vanishes on preventing enamel demineralization. Bovine enamel specimens were obtained, polished and the baseline Knoop microhardness was evaluated. Specimens were stratified into six groups (n = 15), according to the varnish applied: S10—experimental varnish containing 10% of S-PRG fillers, S20—20% of S-PRG fillers, S30—30% of S-PRG fillers; S40—40% of S-PRG fillers; PC (positive control)—5% of NaF; NC (negative control)—no treatment was performed. Half of enamel surfaces were protected to work as a control and varnishes were applied over the unprotected area. A demineralizing pH-cycling was performed, and surface and cross-sectional microhardness were measured. The percentage of microhardness of the treated area was calculated comparing with the untreated area. Statistical analysis was performed by one-way ANOVA and Tukey’s test (p = 5%). All experimental S-PRG varnishes protected against demineralization in relation to no treatment, but S40 was the most effective on the surface. For all depths, S30 and S40 were superior in enamel demineralization prevention than other S-PRG filler concentrations and 5% NaF. It was concluded that S-RPG filler containing varnishes were effective to prevent enamel demineralization. The higher concentrated products were more effective than 5% sodium fluoride on surface demineralization prevention.

Caries Progression Rates Revisited: A Systematic Review

Caries progression seems to follow universal, predictable rates, depending largely on the caries severity in populations: the higher the caries severity, the higher the progression rates. Quantification of these rates would allow prediction of future caries increments. Our aim was to describe caries progression rates in the primary and permanent dentition in Western populations (not in lesions) of children and adolescents. Therefore, we systematically searched MEDLINE-PubMed, Embase, CINAHL, and the Cochrane library for studies reporting caries progression data. Eligibility criteria were reporting empirical data from at least 2 full-mouth dental caries examinations in a closed cohort during a follow-up of at least 3 y, a first examination after 1974, a second examination before the age of 22 y, caries assessed as dentine caries (d₃/D₃), and caries reported in dmfs/DMFS (decayed, missing, and filled surfaces), dmft/DMFT (decayed, missing, and filled teeth), or caries-free participants. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, we described the results for the primary and permanent dentition in a systematic review, performed a meta-analysis for the caries incidence rate in the permanent dentition, and conducted multivariate, hierarchical meta-regression analyses for the caries incidence rate and the increments in DMFS and DMFT. Of the 6,343 unique studies retrieved, 43 studies (56,376 participants) were included for systematic review and 32 for meta-analyses (39,429 participants). The annual decline in caries-free children in the permanent dentition ranged from 0.8% to 10.2%. The annual increment ranged from 0.07 to 1.77 in DMFS and from 0.06 to 0.73 in DMFT. The pooled caries incidence rate was 0.11 (0.09–0.13) per person-year at risk. Meta-regression analyses showed that the methods of individual studies influenced pooled caries incidence rates and increments in DMFS and DMFT. This should be taken into account in planning and evaluation of oral health care services. However, the caries incidence rate is promising for prediction of future caries increments in populations.

Comparative assessment of conventional and light-curable fluoride varnish in the prevention of enamel demineralization during fixed appliance therapy: a split-mouth randomized controlled trial

Objective

To evaluate the effects of single application of a conventional versus light-curable fluoride varnish (LCFV) on prevention of enamel demineralization during fixed orthodontic treatment over a 4 month period.

Design

The research was designed as a split-mouth, randomized control trial (RCT).

Methods

Twenty-two patients requiring fixed orthodontic treatment with premolar extractions were included in the RCT. In each patient, two diagonal quadrants (i.e. upper right and lower left, or vice versa) were randomly assigned to receive conventional fluoride varnish or LCFV. After allocation of one intervention, the other diagonal quadrants received the second intervention. At specific time intervals, premolars were extracted and sectioned, and the demineralized lesion was assessed in each group.

Main outcome measures

The primary outcome was demineralized enamel lesion depth (DELD) at the end of 45, 90, and 120 days.

Randomization

A simple complete randomization list using random allocation rule (restricted randomization) was computer generated to ensure homogeneity of application of conventional or LCFV to each contralateral quadrant in a split-mouth design. Allocation concealment was not employed.

Blinding

Blinding was done only for outcome assessor because of clinical limitations.

Results

Twenty-two patients with 88 teeth were enrolled in the trial. After excluding the drop-outs, primary analysis was performed on 66 teeth distributed among two interventional groups. Mean difference between DELD among two groups was 36.6 µm [95 per cent confidence interval (CI) 34.61-38.55] and 58.5 µm [95 per cent confidence interval (CI) 55.65-61.43] at 90 and 120 days, respectively. Cluster level analysis performed by Paired t-test showed that DELD was significantly higher (P < 0.001) in the conventional fluoride varnish group at the end of 90 and 120 days as compared to LCFV group. No adverse effect was observed in any patient.

Limitations

Being a histologic study, the role of fluoride varnish could be assessed only for 4 months.

Conclusion

The result of this study indicate that single application of LCFV (Clinpro™ XT) can prevent enamel demineralization for longer duration (for up to 4 months) of time as compared to conventional fluoride varnish (Duraphat™, 45 days) during fixed appliance therapy.

Registration

The trial was registered retrospectively in the Clinical Trial Registry-India, number CTRI/2016/09/007232.

Caries outcome following an intensive fluoride varnish treatment regimen for children at high risk for early childhood caries

PURPOSE

To evaluate the caries relapse rate for a cohort of 2- to 4-year-old children at high risk of early childhood caries when treated with an intensive fluoride varnish (FV) regimen.

METHODS

Eighty paediatric patients were recruited. Forty of these patients were high risk and received the FV treatment (three applications within 2 weeks and additional applications at 1 and 3 months) during 2009-2010. Mutans streptococci (MS) levels in the saliva were evaluated during the treatment period. A comparative group of 40 children, selected from an electronic record search at the New York University College of Dentistry to be of similar age, gender, and ethnicity, but not at elevated risk for ECC, received the standard of care (semi-annual FV treatment). Detailed caries examination and treatment records were obtained for all patients from 2009 to 2014.

RESULTS

A significant reduction (P < 0.001) in MS levels was observed in the intensive FV treatment group at the 3-month visit compared with baseline. There was no effect of the intensive FV treatment on caries outcome in the anterior teeth, and the overall caries scores were significantly increased on the posterior teeth.

CONCLUSION

The intensive FV regimen appears insufficient to prevent caries relapse in children at high risk for caries.

Caries Preventive Effect of Sodium Fluoride Varnish on Deciduous Dentition: A Clinical Trial

AIM

The aim of the study is to evaluate the efficacy of intensive application of sodium fluoride varnish in reducing caries incidence among children aged 6 to 7 years.

MATERIALS AND METHODS

The study was a randomized controlled trial conducted among 6- to 7-year-old children of Sangamner, Maharashtra, India. Nearly 200 randomly selected children were randomized into two groups: Control group and intervention (varnish) group. Dental examination to record the caries experiences was conducted at baseline and at 1-year follow-up. The fluoride varnish was applied for three times in a week for a period of 1 year. Mean decayed, missed, and filled teeth (DMFT) were compared between and within groups using t-test.

RESULTS

Out of 200 participants, there were 3 dropouts for control group and 4 for intervention group. Nearly 55% study participants were males and remaining were females. There was a statistically significant difference between the baseline and follow-up caries levels in varnish group for deciduous dentition. Mean caries reduction in this study was 26%.

CONCLUSION

After 1 year of study, we found significant caries reversal in deciduous dentition among the 6- to 7-year-olds after intensive fluoride application. Such a regimen can be advocated to encourage the practitioners and the caregivers alike for early caries prevention.

CLINICAL SIGNIFICANCE

Intensive fluoride application (three times a week) once a year was found to be effective in reducing the incidence of detectable carious lesions and can be advocated to the dental professionals to be incorporated in their routine preventive clinical practice.

Efficacy of Concomitant Therapy with Fluoride and Chlorhexidine Varnish on Remineralization of Incipient Lesions in Young Children

AIM

To assess the effect of combined use of chlorhexidine and fluoride varnish on the remineralization of incipient carious lesions in young children.

MATERIALS AND METHODS

Twenty caries-active children (80 lesions) were randomly divided into four groups and subjected to initial examination. Caries status was assessed visually and with the aid of DIAGNOdent. Baseline enamel biopsies were obtained. Subjects of groups I and II received fluoride and chlorhexidine varnish respectively. Group III received both fluoride and chlorhexidine varnish alternatively, for a period of 4 weeks. Group IV served as the control. At 3-month follow-up, the incipient lesions were assessed again with DIAGNOdent and enamel biopsy.

RESULTS

Increased calcium, phosphate, and fluoride levels were noticed in groups I, II, III compared to group IV, at the 3-month follow-up (p < 0.001).

CONCLUSION

The combined therapy with fluoride and chlorhex-idine varnish may be considered an alternative therapy for early reversal of incipient lesions.

HOW TO CITE THIS ARTICLE

Naidu S, Tandon S, Nayak R, Ratnanag PV, Prajapati D, Kamath N. Efficacy of Concomitant Therapy with Fluoride and Chlorhexidine Varnish on Remineralization of Incipient Lesions in Young Children. Int J Clin Pediatr Dent 2016;9(4):296-302.

Comparative Evaluation of Longevity of Fluoride Release From three Different Fluoride Varnishes - An Invitro Study

INTRODUCTION

Fluoride varnishes play a pivotal role in inhibition of dental caries by increasing remineralization.

AIM

To determine the longevity of fluoride release from 3 different fluoride varnishes over a period of time through salivary fluoride estimation.

MATERIALS AND METHODS

Twenty four extracted human deciduous anterior teeth were divided into four groups, i.e., ClinproTM XT, Flouritop SR, Flourprotector and Control group. Fluoride varnishes were applied on 3mm x 3mm window on labial surface of the teeth and then the teeth were immersed and stored in artificial saliva. The concentration of fluoride in ppm was measured after 1 week, 1 month, 3 months and 6 months. Fluoride release at each time interval for different groups was statistically analyzed using ANOVA and Post Hoc Tukey's test.

RESULTS

Although all the fluoride varnishes released fluoride, with greatest release observed during 1(st) week by Fluoritop SR (66.92±16.30ppm), ClinproTM XT Varnish released consistently and substantially more fluoride than Fluoritop SR and Fluorprotector during 6 months analysis (p<0.05). Fluorprotector showed the lowest rate of F release among all the groups compared.

CONCLUSION

Over a period of 6 months ClinproTM XT Varnish released consistently and substantially more fluoride than other tested products.

Effect of fluoride varnish and chlorhexidine-thymol varnish on mutans streptococci levels in human dental plaque: a double-blinded randomized controlled trial

BACKGROUND

Recent systematic reviews on clinical trials comparing the efficacy of chlorhexidine and fluoride varnish found that the evidence was inconclusive and further well-conducted randomized controlled clinical trials were advocated.

AIM

To compare the effect of fluoride varnish (F) and Chlorhexidine-thymol varnish (CHX/T) with intensive application regimen on mutans streptococci (MS) levels in human dental plaque.

DESIGN

Seventy-five subjects between 6 and 10 years of age were allocated into three groups: Group 1-F varnish (n = 29); Group 2-CHX/T varnish(n = 29); Group 3-placebo varnish (n = 17) by stratified block randomization. After baseline plaque samples were obtained, varnish application was applied and repeated at an interval of 3 days in each group. Plaque samples were repeated at 48 h, 1 month, and 3 months. The samples were spread over mitis-salivarius-bacitracin (MSB) culture media, and the colony-forming units per ml (CFU) were measured.

RESULTS

In both Groups 1 and 2, Wilcoxon matched-pairs signed-rank test revealed significant differences in log CFU values of MS between baseline and 48 h, baseline and 1 month but no significant difference between baseline and 3 months. An intergroup comparison at different time intervals showed that the difference between three groups was statistically insignificant.

CONCLUSION

F varnish and CHX/T varnish, with an intensive regimen application have equivocal effect on MS levels in dental plaque.

A framework for costing diagnostic methods in oral health care: an application comparing a new imaging technology with the conventional approach for maxillary canines with eruption disturbances

OBJECTIVES

The aims were (i) to propose a framework for costing diagnostic methods in oral health care and (ii) to illustrate the application of the framework to the radiographic examination of maxillary canines with eruption disturbances.

METHODS

The framework for costing, following Drummond et al. (2005), includes three elements: (i) identification of different resources used in producing and delivering the service, (ii) measurement of the amount of each resource required and (iii) valuation of the resources in monetary terms. Four data collection instruments were designed - a protocol for apportioning the cost of capital equipment to each diagnostic procedure, separate forms for recording consumable items, for the time of different health care providers used for a diagnostic examination and a patient survey for calculation of the total cost to the patient associated with the examination. The framework was applied to the radiographic examination of maxillary canines with eruption disturbances comparing two imaging methods: (i) a new method with cone beam computed tomography and panoramic radiography and (ii) a conventional method using intraoral and panoramic radiography. The primary analysis was performed from the perspective of the health care system. A separate analysis included patient costs with health care system costs to provide a societal perspective. Comparison of the two perspectives allows consideration of whether any costs savings to the health care system are generated at the expense of greater costs for patients and their families. Data for the cost-analysis were retrieved from 47 patients (mean age 14 years) referred to a department of radiology for examination of maxillary canines.

RESULTS

Application of the framework for costing allowed us to compare the resources used to perform examinations of the two methods. The mean total cost per examination for the new method was 128.38€ and 81.80€ for the conventional method, resulting in an incremental cost per examination of the new method of 46.58€.

CONCLUSIONS

The application of the framework demonstrates the feasibility of measuring and comparing the total costs as well as the distribution of total costs between providers and patients for different approaches to this common examination.

Caries prevention effect of intensive application of sodium fluoride varnish in molars in children between age 6 and 7 years

BACKGROUND

The aim of this study was to evaluate the efficacy of intensive application of sodium fluoride varnish in prevention of caries in molars in children between 6 and 7 years and to evaluate the caries status in molars before and after application of fluoride varnish (Cavity Shield).

MATERIALS AND METHODS

Two hundred fifty children (6-7 years) randomized into varnish and control groups. Children in varnish group received fluoride varnish (Cavity Shield) three times during one week (once every 2 days). Clinical and radiographical examinations of all children were performed prior to the first application of varnish and 1 year later. For evaluation and comparison, all the collected data were subjected to statistical analysis.

RESULTS

At the end of 1 year period, varnish group had 27.7% caries reversal in deciduous dentition which was statistically significant. Though there was a decrease in the caries increment in the permanent dentition, it was not statistically significant.

CONCLUSION

Application of fluoride varnish Cavity Shield three times once a week, once a year either in permanent or in deciduous dentition, is associated with substantial reduction in caries increment.

CLINICAL SIGNIFICANCE

Fluoride varnish can prove to be an effective tool in prevention of dental caries in both primary and permanent dentitions.

Randomized equivalence trial of intensive and semiannual applications of fluoride varnish in the primary dentition

For children in the primary dentition with high caries prevalence the standard semiannual application of fluoride varnish may not be successful in preventing tooth decay. Oftentimes this population is mobile and does not receive consistent preventive care. This trial tested whether an intensive fluoride 5% sodium varnish regimen (three applications/2 weeks) applied annually has an equivalent effect on caries progression in the primary dentition compared to single applications applied semiannually. This study was a randomized clinical trial with two treatment groups. All participants (n = 600; mean age +/- SD = 55.3 +/- 4.6 months) received three varnish applications (active varnish or placebo) at semiannual visits over 3 years. Once per year the intensive-treatment group received one set of three active treatments and three placebo treatments 6 months later, each time within 2 weeks. The standard group received one active and two placebo treatments every 6 months. Children were assessed clinically at baseline and 12, 24 and 36 months after the initiation of the study. The mean (SD) numbers of newly decayed primary tooth surfaces observed over 3 years were 9.8 (8.6) and 7.4 (7.7) in the intensive and standard groups, respectively. The adjusted rate ratio was 1.13 (95% CI = 0.94-1.37, p = 0.20). In conclusion, the trial failed to demonstrate clear evidence of a difference in efficacy. However, differences of up to 36% greater rates of caries in the intensive group could not be ruled out, thus equivalence of the treatments cannot be concluded.

In vitro assessment of an experimental coat applied over fluoride varnishes

Objective:

The time of contact between the product and enamel surface is important in ensuring the efficacy of fluoride varnishes. Thus, some alternatives could avoid fluoride loss to saliva and improve the anticariogenic action of the product. This study evaluated the effect of an experimental coat on the anticariogenic action of fluoride varnishes.

Material and Methods:

Enamel bovine blocks were selected by evaluating surface microhardness and randomized into five groups (n=24): placebo, Duraphat™, Duraphat™ with coat, Duofluorid™ and Duofluorid™ with coat. Twelve blocks from each group were used to analyze calcium fluoride (CaF₂) formed on enamel after treatment. The other 12 blocks were subjected to pH cycling for 7 days. The varnishes were kept on enamel for 6 h. Next, the percentage change of surface microhardness (%SMHC) and mineral loss (ΔZ) were calculated. CaF₂ retained and fluoride present in the pH-cycled solutions were also measured.

Results:

The use of the coat did not decrease %SMHC and ΔZ, but all fluoride varnishes had better results when compared to the placebo (ANOVA and Kruskal-Wallis, respectively). The values from CaF₂ formed were higher compared to the values of CaF₂ retained (non-paired t test, p<0.05). There was a trend to decrease the amount of F in the solutions at the end of pH cycling (Kruskal-Wallis, p<0.05).

Conclusions:

Although the experimental coat increased the formation of CaF₂ on the enamel surface, it did not significantly improve the anticariogenic action of fluoride varnishes.

Cost-analysis of school-based fluoride varnish and fluoride rinsing programs

OBJECTIVE

From a dental care perspective, we analyze whether the prevention of approximal caries by fluoride varnish treatment (FVT) or by fluoride mouth rinsing (FMR) could contain costs in an extended period of follow-up after the end of school-based prevention programs.

MATERIAL AND METHODS

It is assumed in a model that, after 3 years of prevention with either FVT or FMR according to published studies, the "natural course" of approximal caries progression would follow for 5 consecutive years, as described in a Swedish longitudinal study. The outcome and costs of FVT, FMR and controls were modelled from years 4 to 8.

RESULTS

The FVT program had a better outcome in reducing approximal caries than FMR, and costs were lower. The FVT was expected to result in cost containment compared to controls 3 years after the end of the preventive FVT program. The ratio benefits to costs were 1.8: 1 for FVT and 0.9: 1 for FMR.

CONCLUSIONS

Prevention of approximal caries by FVT may result in cost containment, at a benefit cost ratio of 1.8: 1, given that the program can be administered at school.

Dental hygiene participation in managing incipient and hidden caries

With the advent of new caries detection devices that allow early detection, dental hygienists can intervene in the demineralization process and work with the patient toward remineralization through patient self-care procedures and the professional application of topical fluorides. The focus of this article is on caries detection devices, caries risk assessment, agents used to prevent dental caries, and the development of self-care plans for patients that include prevention, intervention, and therapeutic components.

Fluoride varnishes in caries prevention

The first fluoride varnishes were developed during the 1960s (Duraphat) sodium fluoride varnish) and 1970s (Fluor Protector) silane fluoride varnish) to prolong the contact time between fluoride and enamel. Fluoride varnishes adhere to enamel, and calcium fluoride formed after application acts as a long-term reservoir of fluoride. Currently Duraphat varnish is the most widely used topical fluoride for professional application in Europe, and the use of fluoride varnishes is increasing in the USA. Duraphat varnish has been effective in three decades of clinical studies, but the results of Fluor Protector varnish are inconclusive. The percent caries reductions found in the 1990s have generally been lower than those reported in earlier studies, probably because of the higher exposure to other preventive measures in the more recent studies. In studies comparing Duraphat varnish and APF gel, Duraphat varnish was equally or more effective than APF gel. Sealants were most effective in preventing occlusal caries. Four applications per year, or three weekly applications once a year, have been found to be effective. However, several studies have shown that two applications per year may provide comparable results. Application is fast and easy. Professional prophylaxis is not necessary, and the patient can leave immediately after the treatment. No acute toxicity has been reported after using any fluoride varnish.

Professional fluoride varnish treatment for caries control: a systematic review of clinical trials

The aim of this paper was systematically to evaluate the caries-preventive effect of professional fluoride varnish treatments. A search of the literature for articles published between 1966 and August 2003 was carried out in electronic databases, reference lists of articles, and selected textbooks in accordance with the strategy of the Swedish Council on Technology Assessment in Health Care. Out of 302 identified papers, 24 randomized and controlled clinical trials comparing fluoride varnish with placebo, no active treatment or other fluoride preventive regimens of at least 2 years' study duration were included. The trials that met the inclusion criteria were assessed independently and systematically by at least two reviewers and scored from A to C according to predetermined criteria for methodology and performance. The main outcome measure was the preventive fraction expressed as a percentage. The results displayed limited evidence (evidence level 3) for the caries preventive effect of topical applications of fluoride varnishes in permanent teeth. The average prevented fraction was 30% (0-69%) when compared with untreated controls. Inconclusive evidence (evidence level 4) was found for fluoride varnish treatment in the primary dentition and in adults. This systematic review reinforces the need for future dinical research of high quality, incorporating modern concepts of dinical performance and evaluation to assess dental caries control using professional fluoride varnish.

Fluorides for the prevention of white spots on teeth during fixed brace treatment

BACKGROUND

White spots can appear on teeth during fixed brace treatment because of early decay around the brace attachments. Fluoride is effective at reducing decay in susceptible individuals and is routinely prescribed in various different forms to patients during orthodontic treatment.

OBJECTIVES

To evaluate the effectiveness of fluoride in preventing white spots during orthodontic treatment and to compare the different modes of delivery of fluoride.

SEARCH STRATEGY

We searched the Cochrane Oral Health Group's Trials Register (to 22 August 2002); CENTRAL (The Cochrane Library Issue 3, 2002); MEDLINE (January 1966 to July 2003); EMBASE (January 1980 to week July 2003). Authors of trials were contacted for further data.

SELECTION CRITERIA

Trials were selected if they met the following criteria: a randomised or quasi-randomised clinical trial, involving the use of a fluoride-containing product compared with no use or use of a non-fluoride control and enamel demineralisation was assessed during or after orthodontic treatment.

DATA COLLECTION AND ANALYSIS

Six reviewers independently, in duplicate, extracted data. The primary outcome was the difference in the presence or absence of white spots between experimental and control patients for parallel design studies, and between experimental and control quadrants, for split-mouth design studies. Potential sources of heterogeneity were examined. Sensitivity analyses were undertaken for the items assessed for quality and publication bias.

MAIN RESULTS

The primary outcome of the review was the presence or absence of white spots by patient at the end of treatment. Secondary outcomes included any quantitative assessment of enamel mineral loss or lesion depth. Other outcomes such as differences in size and severity of white spots, any patient based outcomes, such as perception of white spots could not be included because there were insufficient data. Fifteen trials, with 723 participants, provided data for this review. None of the studies fulfilled all of the methodological quality assessment criteria. There is some evidence that a daily sodium fluoride mouthrinse reduces the severity of enamel decay surrounding a fixed brace (weighted mean difference for lesion depth -70.0; 95% CI -118.2 to -21.8) and that use of a glass ionomer cement for bracket bonding reduces the prevalence (Peto OR 0.35; 95% CI 0.15 to 0.84) and severity of white spots (weighted mean difference for mineral loss -645 vol%.microm; 95% CI -915 to -375) compared with composite resins.

REVIEWERS' CONCLUSIONS

There is some evidence that the use of topical fluoride or fluoride-containing bonding materials during orthodontic treatment reduces the occurrence and severity of white spot lesions, however there is little evidence as to which method or combination of methods to deliver the fluoride is the most effective. Based on current best practice in other areas of dentistry, for which there is evidence, we recommend that patients with fixed braces rinse daily with a 0.05% sodium fluoride mouthrinse. More high quality, clinical research is required into the different modes of delivering fluoride to the orthodontic patient.

Fluoride varnish for caries prevention: comparisons with other preventive agents and recommendations for a community-based protocol

This paper reviews fluoride varnish (FV) literature to develop a community-based protocol for people with special needs or those who are caries susceptible. Safety, personnel and cost issues are discussed and existing NIH, CDC and WHO recommendations are presented. FV studies are assessed with respect to type of FV to use and frequency of application. FV is compared with studies using other caries preventive agents: 0.2% NaF mouthrinse, acidulated phosphate fluoride (APF) gel, dental sealants, water fluoridation and chlorhexidine. Because there are few FV studies among special need populations, conclusions are based on available literature and public health principles. If personnel are available, FV use is preferred to APF gel and may be preferable to 0.2% NaF mouthrinse. FV is more effective in optimally fluoridated communities. If many occlusal surfaces are at risk, sealants should be applied. Additional combinations and frequencies of preventive agents should be tested, especially for people with special needs and high caries risk adults.

Cost-effectiveness of different caries preventive measures in a high-risk population of Swedish adolescents

OBJECTIVES

A total of 3373 12-year-olds agreed to participate in an intervention study evaluating different caries preventive measures. The study, titled 'Evaluation of caries preventive measures', was performed between 1995 and 1999 at 26 dental health clinics throughout Sweden. At the start of the study, the subjects were classified as individuals at high or low risk of developing caries. The high-risk group consisted of 1165 subjects. The children in the high-risk group were randomly assigned to one of four preventive programs. The programs represent a step-wise increase in fluoride content, contact with dental personnel and cost. The aim of the present cost-effectiveness analysis (CEA) study performed from a societal perspective is to compare costs and consequences of caries preventive programs in a caries high-risk population. By 'costs' is meant both treatment costs and costs contributed by the patient and the patient's family. Costs contributed by patients and their families consist of out-of-pocket expenses, transportation costs, and time. Conclusions are that it is important to consider the perspective from which a study is carried out. Costs contributed by the patient and the patient's family have a high impact on total costs for children and younger adolescents but decrease with time as the adolescents get older. The present study shows an incremental cost-effectiveness of 2043 SEK (8.54 SEK = 1 US dollar, December 1999) per averted decayed enamel and dentine missing and filled surface (DeMFS), of which treatment costs represent 1337 SEK using the unit cost for a nurse. This means a yearly cost of approximately 334 SEK.

Effect of fluoride varnish on demineralization adjacent to brackets bonded with RMGI cement

Far too often a less-than-optimal esthetic result occurs after orthodontic treatment due to demineralization of enamel adjacent to fixed orthodontic appliances in patients with inadequate oral hygiene. In vitro studies have shown that a resin-modified glass ionomer (RMGI) cement and a fluoride varnish might help clinicians combat this problem. The purpose of this study was to evaluate, in vitro, the effect of a fluoride-releasing cavity varnish on inhibition of enamel demineralization adjacent to orthodontic brackets bonded with RMGI and composite resin cements. Brackets were bonded to 48 extracted human third molars. Half were bonded with a composite resin (Transbond, 3M Unitek, Monrovia, Calif) and half with an RMGI (Fuji Ortho LC, GC America, Alsip, Ill). Each group was further divided into 2, with half receiving an application of fluoride-releasing varnish (Duraflor, Pharmascience, Montreal, Québec, Canada). The samples were cycled in an artificial caries solution for an hour twice daily for 31 days. After each caries challenge, the teeth were brushed with a soft toothbrush to simulate normal mechanical wear of the varnish. The loss of fluoride varnish was timed. Teeth were sectioned longitudinally and photographed under polarized light microscopy. Mean lesion depth was measured, and analysis of variance (ANOVA) (P <or=.0001) and the Duncan multiple range test (P <or=.05) indicated significant differences among the groups. Teeth bonded with composite resin showed a 35% reduction in mean lesion depth when fluoride varnish was applied. Teeth bonded with RMGI cement showed no significant differences in lesion depth between varnish and nonvarnish groups. Both RMGI groups had 50% smaller mean lesion depths when compared with the composite resin group without fluoride varnish. Samples bonded with RMGI cement illustrated a wedge effect, with lesion depth shallower near the bracket. A chi-square test showed that the fluoride varnish was lost significantly faster in samples bonded with Fuji Ortho LC (P =.013). Although the fluoride varnish could not prevent demineralization, it appears to be beneficial in reducing lesion formation. Clinicians should consider applying fluoride varnish on areas of enamel that exhibit demineralization or are at risk of demineralization in patients with poor oral hygiene.

Assessing the effect of fluoride varnish on early enamel carious lesions in the primary dentition

BACKGROUND

The aim of this study was to evaluate the effect of fluoride varnish on enamel caries progression in the primary dentition.

METHODS

One hundred forty-two children in Head Start schools (3 to 5 years old) were randomized into the varnish and control groups. Children in the varnish group received fluoride varnish (Duraphat, Colgate-Palmolive Co.) at baseline and after four months, and children in the control group received no professional fluoride applications. Two calibrated examiners performed the examinations at baseline and at nine months.

RESULTS

At nine months, the authors found that in the control group, 37.8 percent of active enamel lesions on occlusal, buccal and lingual surfaces became inactive, 3.6 percent progressed and 36.9 percent did not change. In the varnish group, 81.2 percent became inactive, 2.4 percent progressed and 8.2 percent did not change. The difference between the groups was statistically significant (P < .0001). The mean decayed surfaces, or ds, value in the varnish group was significantly lower after nine months than it was at baseline (P < .0001). When enamel lesions were included in the data analysis (along with dentinal lesions), the decayed with initial enamel lesions, missing and filled surfaces, or dEmfs, values; decayed with initial enamel lesions, missing and filled teeth, or dEmft, values; and decayed surfaces with initial enamel lesions, or dEs, values were significantly lower in the varnish group after nine months than they were at baseline (P < .0001).

CONCLUSIONS

These results suggest that fluoride varnish applications may be an effective measure in reversing active pit-and-fissure enamel lesions in the primary dentition.

CLINICAL IMPLICATIONS

Fluoride varnishes are safe, easy to apply and well-accepted by patients. This study shows that fluoride varnish may offer an efficient, nonsurgical alternative for the treatment of decay in children.

Fluoride varnishes. A review of their clinical use, cariostatic mechanism, efficacy and safety

BACKGROUND

This is a review of the clinical use, cariostatic mechanism, efficacy, safety and toxicity of fluoride varnishes.

TYPES OF STUDIES REVIEWED

The authors reviewed and summarized in vitro, in vivo and in situ studies; clinical trials; demonstration programs; position papers; and editorials published in English in the biomedical literature since 1966.

RESULTS

Extensive laboratory research and clinical trials conducted in Europe and elsewhere show that fluoride varnishes are as efficacious as other caries-preventive agents. Fluoride varnishes are widely used in European caries-preventive programs. The U.S. Food and Drug Administration has cleared these products only as medical devices to be used as cavity liners and for the treatment of hypersensitive teeth. These products have not yet been cleared for marketing in the United States as caries-preventive agents.

CLINICAL IMPLICATIONS

Three fluoride varnishes are currently available in the United States. Semiannual applications are the most proven treatment regimen. Varnishes are safe and easy to apply and set in contact with intraoral moisture.

Efficiency of fluoride programs in the light of reduced caries levels in young populations

Since the late 1930s, when the efficacy of fluoride in caries prevention was first detected, various efficient methods for fluoride delivery have been developed. Nowadays, fluoride is used for caries prevention on a global scale, the most widely used methods being fluoridated toothpaste and water fluoridation. The latter is a typical community-based prevention method, whereas the former method relies on individual motivation. The goal of an efficient community-based fluoride program is to maintain a constant low level of fluoride in as many mouths as possible at as low a cost as possible. Initially, water fluoridation and other community-based programs were highly efficient, but nowadays in societies in which the major part of the population is using fluoride toothpaste and caries levels are low, population-based programs show a low efficiency. As an example, even though water fluoridation was withdrawn in Kuopio, there have been no dramatic effects on the dental health of children and youths. In societies with well-attended, community-based, free dental health care for children and youths, the dental motivation of individuals is, in general, very high and the use of fluoride for caries prevention may be taken care of at the individual level.

Prevention policies in the light of the changed distribution of dental caries

Changes in the distribution of caries in economically developed nations over the last 15-20 years include 1) an overall decline in prevalence and severity in child populations; 2) an increasingly skewed distribution, with most disease now found in a small number of children; and 3) concentration of caries in pit and fissure lesions. Exposure to fluoride is usually seen as the principal reason for the caries decline, with little change in intraoral levels of cariogenic organisms or the annual consumption of sugars. Prevention activities are still most often conducted under policies that were established at a time when caries was a more widespread public health problem, so these policies should be critically examined in the light of modern conditions. While prevention should remain the prime activity of public health agencies, despite the reduced severity of caries, the relative economic efficiency of various procedures should be constantly evaluated. Despite the attractions of targeting, cost-effective prevention should be aimed first at the whole population, with more expensive activities targeted to all children in a chosen geographic area rather than to individually selected children. In the Scandinavian countries the prime population strategies are the regular use of fluoride toothpaste and public education that emphasizes oral hygiene. In selected areas where caries levels are still relatively high (that is, targeted geographic areas), fluoride rinse and tablet programs, provided for a whole classroom at a time, can enhance intraoral fluoride levels where necessary. Fluoride varnish and sealants, though effective, are expensive and need careful selection of locality and teeth to be efficient. Individual children with a persistent caries problem, now relatively small in number, can receive individualized preventive treatment in the clinics of the school dental service.

Methods of evaluating dental care costs in the Swedish public dental health care sector

Twenty-six Swedish dental health care clinics participating in the intervention study "Evaluation of caries preventive measures" have been analysed with focus on costs, with the aim of demonstrating techniques suitable for evaluating direct dental care costs and also finding out whether charges are acceptable as a proxy for real costs. Three different approaches to calculating unit costs are discussed: average treatment time cost and two methods of different allocation of overhead cost. Average treatment time cost shows treatment time cost regardless of who (dentist, dental hygienist or nurse) provides the dental care. The other two methods reflect both the differences of treatment costs depending on practitioners' skill level and competence (salary) and the methods of handling overhead cost allocation. Our conclusions are that the proposed methods seem useful for evaluating costs in cost-effectiveness and cost-benefit analysis. The alternative to average treatment time cost or unit time cost depends on what data is available and the perspective of the analysis. This study also concludes that charges are not sufficient as an alternative to a more detailed cost evaluation, at least not in Swedish public dental health care, since charges do not cover costs.