ARE PIT AND FISSURE SEALANTS EFFECTIVE IN PREVENTING AND ARRESTING OCCLUSAL CARIES IN PRIMARY AND PERMANENT TEETH? AN OVERVIEW OF SYSTEMATIC REVIEWS

OBJECTIVES

To compile the evidence from systematic reviews (SRs) about the use of sealants for preventing and arresting pit and fissure occlusal caries in primary and permanent teeth.

MATERIALS AND METHODS

A search was performed in six databases and gray literature up to May 2023. Systematic reviews (SRs) that included randomized trials (RCTs) and nonrandomized clinical trials (n-RCTs) aiming to answer the PICO-based focused question "are pit and fissure sealants (I) more effective than other interventions, control or no treatment (C) in preventing and arresting occlusal caries (O) in primary and permanent teeth (P)?", were included. The methodological quality was assessed using the AMSTAR-2. The overlap between reviews was calculated (corrected covered, CCA).

RESULTS

Among the 25 included SRs, 18 underwent meta-analysis. Eighteen SRs considered sealing enamel caries lesions, one considered sealing dentine caries, and six considered both. Seventeen SRs were devoted to preventive sealing (RCT only, n = 12; RCT and n-RCT, n = 5), while eight were devoted to prevention and arrest of dental caries (RCT only, n = 5; RCT and n-RCT, n = 3). Nine SRs showed positive results for the primary dentition, and the most frequent periods of follow-up were at least 6 (n = 5) and 12 months (n = 4). According to our meta-analysis, a significant association between resin-based sealants (RBS) and dental caries prevention was detected at 6 months (n = 1) and over longer follow-up periods (n = 4), and the DMFT and dmft indices decreased (n = 2). RBS was better than fluoride varnish at preventing dentine caries (n = 1). A lower caries incidence rate was observed in the resin-modified glass ionomer group at 6 months (n = 1). Overall, the sealants were superior (n = 11), similar (n = 21), or inferior (n = 1) to the other treatments. The AMSTAR-2 scores for studies on preventive sealing were critically low (n = 8), low (n = 6), moderate (n = 1) and high (n = 2) for studies on preventive sealing and critically low (n = 5), low (n = 2) and high (n = 1) for studies on the prevention and arrest of caries lesions. The overlap was low (CCA = 3%).

CONCLUSION

This overview suggests that pit and fissure sealants are not inferior to other interventions in preventing and arresting dental caries lesions in primary and permanent teeth.

Evaluation of the Caries-Arresting Potential of Silver Diamine Fluoride Gel With Potassium Iodide Versus Sodium Fluoride Varnish: An Observational Study

Introduction Silver diamine fluoride (SDF) with potassium iodide (KI) has emerged as a promising, aesthetic, non-invasive management by limiting the staining caused by SDF. However, no studies are comparing the caries-arresting potential of SDF gel with KI. The study aims to observe and evaluate the caries-arresting potential of SDF gel with KI compared to sodium fluoride (NaF) varnish. Materials and methods The present observational study was conducted with a split-mouth design. A total of 33 participants, in the age group of two to six years, with occlusal caries of the International Caries Detection and Assessment System (ICDAS) I and II involving both right and left upper or lower primary molar teeth, were included. SDF gel with KI and fluoride varnish (FV) was applied to the contralateral teeth on the same arch. Participants were recalled at 3, 6, 9, and 12-month intervals to monitor the progression or arrest of carious lesions. Result At the end of 12 months, 66.7% and 70.5% of the teeth showed arrest of caries with SDF gel with KI and FV, respectively. Intra-group analysis using the Friedman test shows significant differences in both groups across the timeline (p=0.001). Intergroup analysis using the Whitney U test reveals no significant difference in caries-arresting potential between the groups at various timelines (p=0.231). Conclusion There was no significant difference in arresting enamel caries of primary teeth between the use of 5% NaF and 38% SDF with KI. However, there was a significant difference within the group between the 3rd and 12th-month follow-up. Hence, the biannual application is recommended in both FV and SDF with KI.

Professionally applied fluorides for preventing and arresting dental caries in low- and middle-income countries: Systematic review

OBJECTIVES

This systematic review aimed to review the safety and effectiveness of professionally applied fluorides for preventing and arresting dental caries in low- and middle-income countries (LMICs).

METHODS

Randomized controlled trials conducted in LMICs, in which professionally applied fluorides were compared with placebo/no treatment/health education only or usual care with a minimum one-year follow-up period, were included. Any topically applied fluoride agents such as sodium fluoride (NaF), acidulated phosphate fluoride, silver diamine fluoride (SDF), and nano silver fluoride (NSF) were included. Five databases (PubMed, Embase, Scopus, Web of Science, and Cochrane Library) were searched in May 2022. Meta-analysis was conducted using a random effect model.

RESULTS

This review included 33 studies for qualitative synthesis, encompassing 16,375 children aged between 1.5 and 14 years. Nevertheless, the meta-analysis focused on only 17 studies, involving 4067 children. Fourteen papers assessed potential adverse events, none of which was reported as major adverse events. SDF and NSF were identified as effective in arresting caries on primary teeth (p < 0.05) compared with a placebo or no treatment. Fluoride varnish and gel were identified as effective in reducing new caries development on primary teeth (p < 0.05) but not on permanent teeth (p > 0.05). The certainty of the generated evidence obtained is low.

CONCLUSION

The review provides valuable insights into the use of professionally applied fluorides in LMICs and contributes to recommendations for their use. However, the limited rigorous evidence suggests the need for further research to strengthen these findings and draw more robust conclusions.

Knowledge of the health personnel involved in the fluoride varnish therapy programs of primary schools in Tehran, Iran

INTRODUCTION

The World Health Organization (WHO) places great importance on oral health promotion programs in schools, given that approximately one billion people worldwide are students. This demographic not only includes the students themselves, but also extends to school staff, their families, and the broader community, all of whom are interconnected. The objectives of this study were firstly to assess the knowledge of health personnel conducting fluoride varnish treatment (FVT) in schools, and secondly to solicit their views on the effectiveness of their training methods.

METHODS

Data was collected from health personnel involved in FVT in schools, supervised by medical universities in Tehran province, using a questionnaire. The questionnaire was divided into four sections: demographic information, methods of receiving FVT training, respondents' knowledge regarding FVT, and opinions about the effectiveness of FVT training methods. The questionnaire was distributed via social media, phone conversations, and email. The collected data was analyzed using Mann-Whitney in SPSS Version 26. A regression model was also fitted to the data.

RESULTS

The present study included 403 participants. Among various educational methods, it was found that participation in previous workshops (P = 0.001) and FVT workshops (P = 0.013) was significantly correlated with a higher FVT knowledge score. Additionally, participation in previous oral health promotion programs was significantly associated with a higher knowledge score (P < 0.05). Therefore, a history of participating in previous health promotion programs significantly contributed to the participants' knowledge.

CONCLUSION

Participation in previous oral health programs was found to be significantly correlated with a higher knowledge score. The effectiveness of training programs can be attributed to participation in previous workshops and FVT workshops. This study provided insights into potential strategies for enhancing personnel training in national oral health programs.

Interplay Between Minerals in Bottled Water and Fluoride Toothpaste and Caries Lesion Remineralization

OBJECTIVES

he aim of this in vitro study was to evaluate the effects of some bottled waters on fluoride toothpaste efficacy in enhancing caries lesion remineralization.

METHODS

Early caries lesions were created in bovine enamel specimens and stratified into treatment groups based on Vickers surface microhardness (VHN). The present study followed a two (fluoride and fluoride-free toothpaste) by five (four bottled waters and tap water) factorial design. The treatment groups were bottled water with the following attributes: (a) 309.9 ppm Ca/1.20 ppm F; (b) 118.4 ppm Ca/0.16 ppm F; (c) 1.00 ppm Ca/1.01 ppm F; and (d) 0.1 ppm Ca/0.04 ppm F and tap water (48.7 ppm Ca/0.7 ppm F). The five water groups were paired either with 1100 ppm fluoride or fluoride-free toothpaste, yielding 10 groups. Specimens were pH-cycled for 10 days with the daily regimen comprised of twice daily toothpaste slurry, with four exposures to water in between. VHN was measured again and the difference was calculated (ΔVHN). Data were analyzed using two-way ANOVA at a 5% significance level.

RESULTS

The two-way interaction between water and toothpaste was significant (p<0.001). All groups except fluoride-free toothpaste/bottled water with 0.1 ppm Ca/0.04 ppm F (p=0.411) had significant increases in VHN after pH cycling (p≤0.023). Fluoridated toothpaste resulted in a higher rate of remineralization compared to fluoride-free toothpaste (all p<0.001). Bottled water with 1.20 ppm F/309.9 ppm Ca exhibited the greatest extent of remineralization within fluoride toothpaste groups (p<0.001) and higher remineralization than lower fluoride water in fluoride-free toothpaste groups (p≤0.006). Within the fluoridated toothpaste group, tap water exhibited significantly less remineralization than all bottled waters (all p<0.001).

CONCLUSION

Within the limitation of this study, bottled water with higher fluoride and calcium concentrations might improve fluoridated toothpaste efficacy by enhancing remineralization of early enamel caries-like lesions.

Quality Measure Adherence and Oral Health Outcomes in Children

Importance

Process-based quality measures are generally intended to promote evidence-based practices that have been proven to improve outcomes. However, due to lack of standardized implementation of diagnostic codes in dentistry, assessing the association between process and oral health outcomes has been challenging.

Objective

To estimate the association of adhering to dental quality measures with patient oral health outcomes.

Design, Setting, and Participants

Using a target trial emulation, a causal inference framework, this retrospective cohort study estimated the difference in the risk of developing tooth decay between US children who adhered to process-based dental quality measures (receiving topical fluoride and sealant [treated groups]) and those who did not (control groups). Electronic health records of US children and adolescents aged 0 to 18 years from January 1, 2014, to December 31, 2020, were used. To emulate random treatment assignment based on baseline confounders, coarsened exact matching was used to produce covariate balance between the treated and control groups. A time-to-event regression model produced effect estimates, adjusting for time-varying covariates. Near-far matching was used to account for unmeasured confounders as a sensitivity analysis. Data were analyzed from May 1 to August 7, 2023.

Exposures

Adherence to dental quality measures.

Main Outcomes and Measures

Incidence of tooth decay.

Results

Among 69 212 US children aged between 0 and 18 years (mean [SD] age, 10.2 [5.0] years; 49.5% male, 50.4% female, and 0.1% unknown or transgender), 1930 (2.8%) were Asian, 2038 (2.9%) were Black, 8667 (12.5%) were Hispanic, 33 632 (48.6%) were White, and 22 945 (33.2%) were multiracial, other, or missing racial and ethnic group identification. Relative to control individuals, treated individuals were more likely to be at elevated risk of caries (fluoride measure: 16 453 [76.5%] vs 15 236 [39.8%]; sealant measure: 2264 [54.6%] vs 997 [44.0%]) and have regular dental visits (fluoride measure: 21 498 [100%] vs 13 741 [35.9%]; sealant measure: 1623 [39.2%] vs 871 [38.4%]). Adherence to quality measures was associated with reduced risk of tooth decay with adjusted hazard ratios of 0.82 (95% CI, 0.78- 0.86) for fluoride and 0.86 (95% CI, 0.76-0.97) for sealant in the matched cohort. Benefits of adhering to quality measures were greater among children at elevated vs low risk and with public vs commercial insurance for both measures.

Conclusions

In this cohort study, adhering to dental quality measures was associated with reduced risk of tooth decay, and benefits were greater among children at elevated risk and with public insurance. These findings provide insights in facilitating targeted application of quality measures or developing more tailored quality improvement initiatives.

Health professionals' recommendations on the use of fluoride varnish for caries prevention in preschool children

BACKGROUND

Fluoride varnish (FV) is widely recommended for caries prevention in preschool children, despite its anticaries benefits being uncertain and modest. Dentists often report using clinical practice guidelines (CPGs) as a source of scientific information.

AIM

To identify and analyze recommendations for clinical practice on the use of FV for caries prevention in preschool children and to assess the methodological quality of the CPG on this topic.

DESIGN

Two researchers independently used 12 search strategies and searched the first five pages of Google Search™ and three guideline databases for recommendations freely available to health professionals on the use of FV for caries prevention in preschoolers. Then, they retrieved and recorded recommendations that met the eligibility criteria and extracted the data. A third researcher resolved disagreements. Each included CPG was appraised using the AGREE II instrument.

RESULTS

Twenty-nine documents were included. Recommendations varied according to age, patients' caries risk, and application frequency. Of the six CPGs, only one scored above 70% in the AGREE II overall assessment.

CONCLUSION

Recommendations on the use of FV lacked scientific evidence, and CPGs were of poor quality. Application of FV is widely recommended despite recent evidence showing an uncertain, modest, and possibly not clinically relevant anticaries benefit. Dentists should be aware that it is necessary to critically appraise CPGs since they may be of poor quality.

Effectiveness of silver diamine fluoride versus sodium fluoride varnish combined with mother's motivational interviewing for arresting early childhood caries: a randomized clinical trial

BACKGROUND

Silver Diamine Fluoride (SDF) has gained attention as one of the minimally invasive modalities to manage ECC although it causes black staining of treated carious lesions. A possible affordable alternative may be Sodium Fluoride (NaF) varnish combined with good oral hygiene promoted by parental Motivational Interviewing (MI). The study compared the effectiveness of 38% SDF solution and 5% NaF varnish supported by parental MI in arresting ECC.

MATERIALS AND METHODS

Children aged ≤ 4 years old with at least one active carious lesion (ICDAS score ≥ 3) were randomly assigned to treatment by a single application of 38% SDF solution or a single application of 5% NaF varnish supported by two MI sessions for mothers at baseline and after three months. Chi-Squared test was used to compare groups and multilevel logistic regression analysis was used to assess the effect of the interventions on ECC arrest adjusting for confounders. The interaction between the type of intervention and baseline lesion severity, moderate (ICDAS 3/4) or advanced (ICDAS 5/6), was also assessed.

RESULTS

The study included 165 children with 949 active lesions. After 6 months, there were no significant differences between SDF and NaF/MI groups in overall caries arrest (63.7% and 58.1%, p = 0.08), and in moderate lesions (72.9% and 69.6%, p = 0.52). However, in advanced lesions, the arrest rate was significantly higher in the SDF than the NaF/ MI group (60.3% and 50.0%, P = 0.01). Multilevel multiple logistic regression showed no significant differences between the interventions (AOR = 1.56, P = 0.27) with significant interaction between the intervention and baseline lesion severity (p < 0.001). Moderate lesions treated with SDF (AOR = 3.69, P = 0.008) or NaF/MI (AOR = 3.32, P < 0.001) had significantly higher odds of arrest than advanced lesions treated with NaF/ MI with no difference between advanced lesions treated with SDF or NaF/ MI (AOR = 1.85, P = 0.155) in arrest rate.

CONCLUSION

NaF/ MI can be an alternative to SDF in arresting advanced and moderate ECC lesions without staining with stronger effect on moderate lesions (ICDAS 3/4).

TRIAL REGISTRATION

The trial was retrospectively registered at clinicaltrial.gov registry (#NCT05761041) on 9/3/2023.

Clinical interventions with various agents to prevent early childhood caries: A systematic review with network meta-analysis

BACKGROUND

Dental caries is one of the most prevalent chronic diseases among preschool children globally. Different preventive agents and combinations have been studied. However, the rank of the effectiveness of clinical interventions is equivocal.

AIM

To summarize and rank the effectiveness of clinical interventions using different agents for primary prevention of early childhood caries (ECC).

DESIGN

Two reviewers independently searched PubMed, Embase, and Cochrane Library to identify randomized controlled trials with at least 12-month follow-up. The network meta-analysis (NMA) on different agents was based on a random-effects model and frequentist approach. Standardized mean differences (SMD) with 95% CI of the caries increment were calculated in terms of either dmft or dmfs and used in the NMA. Caries incidences at the child level were compared using odds ratios (ORs) with 95% CI. The effectiveness of the agents was ranked using the surface under the cumulative ranking curve (SUCRA).

RESULTS

After screening 3807 publications and selection, the NMA finally included 33 trials. These trials used either a single or combination of agents such as fluorides, chlorhexidine, casein phosphopeptide-amorphous calcium phosphate, probiotics, xylitol, and triclosan. Compared with control, fluoride foam (FF; SMD -0.69, 95% CI: -1.06, -0.32) and fluoride salt (F salt; SMD -0.66, 95% CI: -1.20, -0.13) were effective in preventing caries increment. Probiotic milk plus low fluoride toothpaste (PMLFTP; OR 0.34, 95% CI: 0.15, 0.77), FF (OR 0.48, 95% CI: 0.37, 0.63), fluoride varnish (FV; OR 0.63, 95% CI: 0.48, 0.81), and fluoride varnish plus high fluoride toothpaste (FVHFTP; OR 0.73, 95% CI: 0.57, 0.93) were effectively preventing caries incidence. According to the SUCRA, FF ranked first in preventing caries increment, whereas PMLFTP ranked first in preventing caries incidence.

CONCLUSION

Fluoride foam, F salt, PMLFTP, FV, and FVHFTP all effectively reduce caries increment or caries incidence in preschool children, but the evidence indicates low degree of certainty. Considering the relatively small number of studies, confidence in the findings, and limitations in the study, clinical practitioners and readers should exercise caution when interpreting the NMA results.

Economic evaluation of fluoride varnish application in preschoolers: A systematic review

BACKGROUND

Fluoride varnish (FV) is a convenient way of professionally applying fluoride in preschoolers. However, its modest anticaries effect highlights the need for economic evaluations.

AIM

To assess economic evaluations reporting applications of FV to reduce caries incidence in preschoolers.

DESIGN

We included full economic evaluations with preschool participants, in which the intervention was FV and the outcome was related to dentin caries. We searched in CENTRAL; MEDLINE via PubMed; WEB OF SCIENCE; EMBASE; SCOPUS; LILACS; BBO; and BVS Economia em saúde, OpenGrey, and EconoLit. Clinical trial registers, thesis and dissertations, and meeting abstracts were hand searched, as well as 11 dental journals. Risk of bias in the included studies was assessed using the Philips' and Drummond's (full and simplified) tools.

RESULTS

Titles and abstracts of 2871 articles were evaluated, and 200 were read in full. Eight cost-effectiveness studies were included: five modeling and three within-trial evaluations. None of the studies gave sufficient information to allow a thorough assessment using the bias tools. We did not combine the results of the studies due to the great heterogeneity among them. Four studies reported that FV in preschool children was a cost-effective measure, but in one of these studies, sealants and fluoride toothpaste were more cost-effective measures than the varnish, and three studies used limited data that compromised the generalizability of their results. The other four studies showed a large increase in costs due to the application of varnish and/or low cost-effectiveness.

CONCLUSION

We did not find convincing overall evidence that applying FV in preschoolers is an anticaries cost-effective measure. The protocol of this systematic review is available at Open Science Framework (https://osf.io/xw5va/).

Comparative evaluation of fluoride-free remineralization agents with and without Er,Cr:YSGG laser on artificial enamel remineralization

This study aimed to evaluate the efficacy of fluoride-free remineralizing agents in initial enamel caries, with and without combined Er,Cr:YSGG laser application. The remineralization effect of various agents and their combinations on artificial initial caries was investigated using 10 experimental groups (n = 7): NC, negative control; PC, positive control; TM, calcium-phosphate compounds (CPP-ACP); TD, theobromine-containing toothpaste; RG, ROCS® remineralizing gel; L, Er,Cr:YSGG laser (2780 nm; 0.25 W; repetition rate, 20 Hz; pulse duration, 140 μs; tip diameter, 600 μm; without air/water cooling); L + fluoride toothpaste; L + TM; L + TD; and L + RG. The demineralized bovine enamel specimens were subjected to an 8-day pH cycle by daily application of the remineralizing agents and laser therapy once prior to the pH cycle and paste application. The enamel samples underwent the Vickers surface microhardness test, and one sample per group was analyzed with scanning electron microscopy. The Kruskal Wallis test was used to compare the microhardness recovery percentage (SMHR%) for each group, and multiple comparisons were made with the Dunn test. Groups L (p = 0.003), RG (p = 0.019), L + TM (p < 0.001), L + fluoride toothpaste (p = 0.001),and L + RG (p = 0.036) exhibited significant increase in SMHR%. The tested remineralizing agents exhibited no statistically significant difference in effect when used alone and in combination with Er,Cr:YSGG laser. Combined application of Er,Cr:YSGG laser and ROCS® remineralization gel effectively promoted enamel remineralization, while use of CPP-ACP and fluoride toothpaste alone was ineffective. Theobromine-containing toothpaste exhibited the least SMHR%. Long-term evaluation of these agents is recommended.

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.

Private Interests and the Start of Fluoride-Supplemented High-Carbohydrate Nutritional Guidelines

Fluoride has no tangible health benefits other than preventing dental caries and there is a small difference between its minimum effective dose and its minimum toxic dose. Leading global organizations currently recommend fluoride supplementation because they recommend high-carbohydrate diets which can cause dental caries. Low-carbohydrate diets prevent dental caries making such fluoride recommendations largely unnecessary. A dental organization was among the first to initiate the public health recommendations which started fluoride-supplemented high-carbohydrate nutritional guidelines. This start required expert panels at this dental organization to reverse on three key scientific points between 1942 and 1949: (1) that topical fluoride had potential harms, (2) that dental caries was a marker for micronutrient deficiencies, and (3) that low-carbohydrate diets are to be recommended for dental caries prevention. Internal documents show that private interests motivated the events which led these expert panels to engage in pivotal scientific reversals. These private interests biased scientific processes and these reversals occurred largely in an absence of supporting evidence. It is concluded that private interests played a significant role in the start of public health endorsements of fluoride-supplemented high-carbohydrate nutritional guidelines.

Risk factors for and prevention of caries and dental erosion in children and adolescents with asthma

There are many studies and reviews of the relationship between the asthma disease in young individuals on the one hand and caries and dental erosion on the other. The causes of caries and dental erosion might be related to the asthmatic drugs, low pH and the sweeteners that the inhaled drug contains and perhaps even the lifestyle of children and adolescents with asthma. The main focus of this review is therefore to describe various preventive strategies, based on long experience of preventive dental care in Sweden. Two fact boxes are presented, one on fluoride toothpaste as a population-based intervention for different ages and one on diet counselling in children and adolescents with asthma. The most important thing is to introduce fluoride toothpaste early in the child's life and that the parents brush the child's teeth twice a day, in the morning after breakfast and at night before bedtime, up to the age of 10. Moreover, a high-risk approach with an additional fluoride supply at home is presented, together with the application of fluoride varnish at the clinic. Regarding diet counselling, it is important to make sure that the child has regular meals during the day, maximum five to six times a day, to allow the teeth to rest between meals and restrict sweets and soft drinks to once a week. It is important to identify children and adolescents with asthma as early as possible and to refer them to a dental team for preventive treatment.

The Effect of MI Varnish™ on Caries Increment and Dietary Habits among 6- and 12-Year-Old Children in Riga, Latvia: A 3-Year Randomized Controlled Trial

Aims: This randomized controlled trial investigated the effect of MI Varnish™ (5% NaF/CPP-ACP) on caries increment in 6- and 12-year-old children in Riga, Latvia within 36 months. Methods: Forty-eight 6-year-old children (Group 1) and forty-seven 12-year-old children (Group 3) received quarterly varnish application, while forty-eight 6-year-old children (Group 2) and thirty-seven 12-year-old children (Group 4) did not have varnish applied. All children/parents received the same preventive advice. All children were visually examined using ICDAS-II criteria. Questionnaires on dietary habits were completed by the children/parents at baseline and after 36 months. DMFS and dfs were calculated from ICDAS data. The statistical analysis was performed (α = 0.05) using a Chi-squared test, paired t-test (Welch test) and the Pearson correlation coefficient. The trial registration number is ISRCTN10584414. Results: In Group 1 versus Group 2, the DMFS(SD) (Baseline/36 months) values were 5.02(5.85)/13.21(6.67) (p < 0.001) versus 2.65(4.54)/10.81(6.14) (p < 0.001), respectively; the dfs(SD) (Baseline/36 months) values were 36.75(12.96)/24.04(12.9) (p < 0.001) versus 33.67(12.74)/23.88(11.91) (p < 0.001), respectively. In Group 3 versus Group 4, the DMFS(SD) (Baseline/36 months) values were 48.62(23.18)/70.96(23.28) (p < 0.001) versus 34.73(17.99)/54.95(16.09) (p < 0.001), respectively; the dfs(SD) (Baseline/36 months) values were 1.7(4.4)/0 (p < 0.05) versus 2(6.39)/0 (p = 0.06), respectively. The prevalence of caries (dfs + DMFS) decreased by 4.52 (p < 0.001) and 1.63 (p < 0.001) in Groups 1 and 2, respectively, but increased by 20.64 (p < 0.001) and 18.22 (p < 0.001) in Groups 3 and 4, respectively. An analysis of the questionnaires indicated the habitual, frequent consumption of a sugary diet by all the children. A significant correlation (r = 0.321; p < 0.05) was observed between caries increment and the frequency of daily intake of sugary snacks, soft drinks and tea with sugar at baseline only in Group 1. Conclusions: A quarterly application of MI varnish (CPP-ACP/fluoride) reduced caries increment in 6- and 12-year-old children in Riga, Latvia.

Caries Experience and Increment in Children Attending Kindergartens with an Early Childhood Caries Preventive Program Compared to Basic Prophylaxis Measures-A Retrospective Cohort Study

Dental caries constitutes a public health challenge. As preventive strategies are desirable, this retrospective cohort study aimed to assess the caries experience and increment in children attending kindergartens with an early childhood caries (ECC) preventive program (intervention group, IG) compared to basic prophylaxis measures (control group, CG) located in areas of different socioeconomic status (SES) within Marburg (Germany). The long-term caries experience (2009−2019) of these 3−5-year-old kindergarten children was evaluated. For the caries increment, dental records of 2019 were screened for the availability of a minimum of two dental examinations at least 8 months apart. Caries was scored according to the WHO criteria (dmf−t). The data were split by observation period (300−550 and >550 days). Overall, 135 children (Ø 3.7 years) attended IG, and 132 children (Ø 3.6 years) attended CG. After 300−550 days, no significant differences were found between both groups regarding mean caries increment and experience (p > 0.05). After >550 days, IG with low SES exhibited a high caries experience. Fluoride varnish applications could not reduce the caries increment compared to CG in the short-term but slightly decreased the long-term caries experience. Comprehensive ECC prevention measures actively involving parents are needed to overcome the caries burden.

Cost-effectiveness of probiotics and fluoride varnish in caries prevention in preschool children

OBJECTIVES

The purpose of this study was to evaluate the cost-effectiveness of two preventive interventions aimed at increasing the proportion of caries-free preschool children of low socioeconomic status using a decision analytic model.

METHODS

Two scenarios were tested, one with a school milk program (SMP) and one without (non-SMP). Fluoride varnish (FV) and a probiotic (PB) were compared to a do-nothing alternative among children in public nurseries/schools over a 4-year period. FV was applied biannually and a PB (Lactobacillus rhamnosus) added to milk powder prepared daily. A Markov decision tree model was utilized. Several sources of data were used to populate the model. Probabilistic and deterministic sensitivity analyses were performed, and a public provider perspective was used.

RESULTS

In the SMP scenario, PB was more effective and less costly than FV and, compared with do-nothing, increased the proportion of caries-free children by 14.5%, with a cost of USD 12.5 per child (June 2018). PB presented an incremental cost-effectiveness ratio (ICER) or cost per extra caries-free child of USD 86.2. In the non-SMP scenario, both interventions were cost-effective. FV (compared with do-nothing) increased the percentage of caries-free children by 8.3% with an ICER of USD 338.3 and PB (compared with FV) increased the effect by 6.2% with an ICER of USD 1400.2.

CONCLUSIONS

The findings showed that PB was most effective and less costly than FV in the SMP scenario only. This type of analysis and its results provide essential information for decision-makers to improve the oral health of preschool children.

Comparison of the Effect of Diode Laser Irradiation and Fluoride Varnish on Salivary Streptococcus mutans Bacterial Colonies Counts: A Randomized Controlled Clinical Trial

Aim

The aim of this study was to assess antibacterial effects of diode laser irradiation and fluoride varnish on Streptococcus (S) mutans bacterial colonies counts in saliva.

Materials and Methods

This was a randomized controlled clinical trial research, in which 36 healthy caries-free schoolchildren aged 7-10 years referred to Birjand University dental school were selected randomly. None of the subjects had used any fluoride products before sampling. They divided into three groups: Group A: Diode laser irradiation, Group B: Fluoride varnish (FV) + diode laser irradiation, and Group C: FV. From each child, the baseline unstimulated saliva samples were obtained, transferred to the mitis salivarius agar (MSA) culture media and assessed for S. mutans colonies counts. The follow-up unstimulated saliva samples were collected one day after the treatments. Then the number of colony-forming units per milliliter were counted and analyzed statistically using Wilcoxon, Mann Whitney U and Kruskal-Wallis tests (p ≤ 0.05).

Results

No adverse events were reported. Salivary count of S. mutans significantly decreased in all groups. The highest and lowest number of the colonies of S. mutans in treated groups was observed in group I and group II, respectively. S. mutans was not completely eliminated by any of the treatments.

Conclusion

Considering the limitations of this study, antimicrobial efficacy of fluoride varnish + diode laser was higher than that of FV or diode laser alone. So this laser in combination with fluoride varnish may be useful in prevention of dental caries and antimicrobial treatment protocols.

Clinical trial registry

IRCTID: IRCT 201,706 181,7756N20

How to cite this article

Darmiani S, Yousefi M, Rad MS. Comparison of the Effect of Diode Laser Irradiation and Fluoride Varnish on Salivary Streptococcus mutans Bacterial Colonies Counts: A Randomized Controlled Clinical Trial. Int J Clin Pediatr Dent 2022;15(S-2):S239-S241.

The effectiveness of behaviour change interventions delivered by non-dental health workers in promoting children’s oral health: A systematic review and meta-analysis

Objectives

Dental caries is the most common preventable childhood condition. Non-dental professionals and health workers are often well placed to support parents in adopting positive oral health behaviours for their children. The aim of this study was to determine the effectiveness of behaviour change interventions and their individual component behaviour change techniques (BCTs), that were delivered by non-dental professionals and health workers.

Methods

A systematic search of Ovid MEDLINE, PubMed, CINAHL, Cochrane Library, Web of Science, TRoPHI and PROQUEST from inception until March 2021 was conducted. Randomised controlled trials and quasi-experimental studies for improving oral health outcomes in children were included. Quality assessment was carried out using Cochrane Risk of Bias tool and ROBINS-I tool. Publication bias was assessed using funnel plots and Egger’s regression intercept. Effect sizes were estimated as standardised mean difference (SMD) and odds ratio/risk ratio for proportions. Meta-analyses were performed for studies reporting mean decayed, missing, filled surfaces (dmfs) and mean decayed, missing, filled, teeth (dmft) indices. Behaviour change technique coding was performed using behaviour change technique taxonomy v1 (BCTTv1).

Results

Out of the 9,101 records retrieved, 36 studies were included with 28 showing a significant effect either in clinical and/or behavioural/knowledge outcomes. Most studies (n = 21) were of poor methodological quality. The pooled SMD for caries experience showed statistically significant result for caries prevention at surface level -0.15 (95% CI -0.25, -0.04) and at the tooth level -0.24 (95% CI -0.42, -0.07). In 28 effective interventions, 27 individual BCTs were identified and the most frequently used were: “Instructions on how to perform the behaviour” and “Information about health consequences”.

Conclusion

There is low quality of evidence suggesting non-dental professionals and health workers may help improve oral health outcomes for children. To confirm these findings, further high-quality studies incorporating a variety of BCTs in their interventions for adoption of good oral health behaviours are needed.

Minimally Invasive Therapies for the Management of Dental Caries—A Literature Review

In recent years, due to a better understanding of the caries pathology and advances in dental materials, the utilization of non-invasive and minimally invasive techniques that delay/obviate the need for traditional restorations has started gaining momentum. This literature review focuses on some of these approaches, including fluoride varnish, silver diamine fluoride, resin sealants, resin infiltration, chemomechanical caries removal and atraumatic restorative treatment, in the context of their chemistries, indications for use, clinical efficacy, factors determining efficacy and limitations. Additionally, we discuss strategies currently being explored to enhance the antimicrobial properties of these treatment modalities to expand the scope of their application.

Topical fluoride to prevent early childhood caries: Systematic review with network meta-analysis

OBJECTIVES

To summarize the evidence on prevention of early childhood caries (ECC) by professionally or self-applied topical fluorides using network meta-analysis.

DATA

Randomized-controlled trials with minimum 1-year follow-up assessing caries-preventive effect among children younger than six years.

SOURCES

Eight electronic databases and grey literature.

STUDY SELECTION

After screening and data extraction, risk of bias assessment using Cochrane risk of bias tool 2.0 was done. Twenty-four trials were included, among which 17 were assessed as "high risk" and remaining as "low risk". Fifteen studies evaluated professionally-applied, and the other nine used self-applied topical fluorides. Ten studies on professionally-applied fluorides reporting the net caries increment (dmfs increment) at 2-years follow-up were included in Network meta-analysis (NMA). NMA and ranking the interventions were conducted using a frequentist random-effects approach and surface under the cumulative ranking command, followed by assessing the certainty of evidence using an extension of GRADE approach with CINeMA framework. Among the eight included interventions of professionally-applied fluorides, only two, i.e., 3-monthly 0.9% difluorosilane (DFS) and 6-monthly 5% sodium fluoride varnish were effective in preventing ECC compared to control with 3-monthly DFS application ranking higher than 6-monthly sodium fluoride varnish application.

CONCLUSION

Among all the professionally-applied topical fluoride interventions reviewed, very low to moderate evidence was found with 0.9% DFS application at 3-monthly intervals, which was ranked highest in prevention of ECC. Among the included studies on self-applied topical fluorides, the evidence was inconclusive due to heterogeneity among studies.

CLINICAL SIGNIFICANCE

The 0.9% DFS varnish applied every 3 months is most effective for preventing early childhood caries. The review recommends that good quality studies be conducted in future, comparing two or more interventions for both self- as well as professionally-applied topical fluoride agents with adequate follow-up.

Cost-effectiveness and efficacy of fluoride varnish for caries prevention in South African children: A cluster-randomized controlled community trial

OBJECTIVES

This cluster-randomized controlled community trial aimed to assess the efficacy and costs of fluoride varnish (FV) application for caries prevention in a high-risk population in South Africa.

METHODS

513 children aged 4-8 years from two schools in a township in South Africa were randomly allocated by class to the FV or Control (CO) groups. In addition to supervised toothbrushing with fluoridated toothpaste in both groups, FV was applied in 3-month intervals by trained local non-professional assistants. Intraoral examinations were conducted at baseline, 12, 21 and 24 months. Primary outcome was the increment of teeth with cavitated lesions (i.e. newly developed or progressed, formerly non-cavitated lesions), requiring restoration or extraction over the study period. Additionally, treatment and re-treatment costs were analyzed.

RESULTS

513 children (d_1-4 mft 5.9 ± 4.3 (mean ± SD)) were randomly allocated to FV (n = 287) or CO (n = 226). 10.2% FV and CO teeth received or required a restoration; 3.9% FV and 4.1% CO teeth were extracted, without significant differences between groups. While FV generated high initial costs, follow-up costs were comparable in both groups, resulting in FV being significantly more expensive than CO (1667 ± 1055 ZAR vs. 950 ± 943 ZAR, p < .001).

CONCLUSIONS

Regular FV application, in addition to daily supervised toothbrushing, had no significant caries-preventive effect and was not cost-effective in a primary school setting within a peri-urban, high-risk community in South Africa. Alternative interventions on community or public health level should be considered to reduce the caries burden in high-risk communities.

Association between sugary drinks consumption and dental caries incidence among Taiwanese schoolchildren with mixed dentition

OBJECTIVES

Dental caries is a multifactorial disease, and a sugary diet can generate an acidic plaque environment that advances its development. However, the specific effect of sugary drinks on the subsequent oral health of schoolchildren with mixed dentition is unclear. In this study, we investigated the association between the consumption of sugary drinks and 1 year incidence rate of caries in permanent teeth among Taiwanese schoolchildren with mixed dentition.

METHODS

A longitudinal 1 year follow-up study was conducted among Taiwanese schoolchildren aged 8-9 years. A questionnaire collected information regarding the parents' oral health status and their children's demographic background, oral health-related behaviours and consumption habits of sugary drinks, including handmade drinks (specifically bubble tea and pearl milk tea) and carbonated drinks. Dental caries was recorded through standardized oral examinations. The number of dental services received was retrieved from the Taiwan National Health Insurance Research Database. Multivariate Cox proportional hazards models and zero-inflated negative binomial models were used to estimate the association between the consumption of sugary drinks and the incidence rate of caries in permanent teeth after 1 year.

RESULTS

The study involved 494 children. During the 1 year follow-up period, 117 children developed new dental caries in their permanent teeth, yielding a caries incidence rate of 0.183 per person-year. After adjustments for confounding factors, children who preferred having sugar-rich beverages were associated with having a 4.3 times higher (95% confidence interval [CI] = 1.2-15.7) risk of developing caries than did those who preferred nonsugary drinks (P < .05). Additionally, children who often consumed handmade drinks were associated with having a 1.7 times higher (95% CI = 1.1-2.9) risk of developing caries than those who seldom consumed (P < .05).

CONCLUSIONS

The findings suggest that the consumption of sugary drinks during the mixed dentition stage might be a major etiological factor for caries in permanent teeth. These findings could be valuable to paediatricians, dentists, nutritionists and policymakers.

The additional benefit of professional fluoride application for children as an adjunct to regular fluoride toothpaste: a systematic review and meta-analysis

OBJECTIVE

To assess whether professional fluoride application (PFA) used in addition to regular fluoride toothpaste (RFT, ≥ 1,000 ppm) is more effective than RFT alone in children.

MATERIALS AND METHODS

A systematic search was conducted using the PubMed, Embase, Google Scholar and CENTRAL databases. Randomized controlled trials (RCTs) comparing the effectiveness of RFT + PFA and RFT alone were included. Meta-analyses with random-effects models were performed. The certainty of evidence was assessed using the GRADE approach.

RESULTS

A total of 2,729 records were identified from electronic and manual searches, which were screened by two reviewers independently and in duplicate. Six RCTs (5,034 participants) were included, of which four had high risk of bias and two had unclear risk of bias. The PFA used in all these trials was fluoride varnish (FV). In meta-analyses, no significant difference was observed between participants receiving FV + RFT and RFT alone of d(m/e)fs increment (mean difference (MD) - 0.17, 95% confidence interval (CI) - 0.60 to 0.26, P = 0.43, I² = 38%; 6 trials, 5,034 participants, moderate certainty evidence), incidence of caries (risk ratio (RR) 0.91, 95% CI 0.80 to 1.05, P = 0.21, I² = 41%; 4 trials, 4,487 participants, moderate certainty evidence) or changes in prevalence of caries (RR 0.89, 95% CI 0.78 to 1.01, P = 0.07, I² = 0%, 4 trials, 4,189 participants, low certainty evidence).

CONCLUSIONS

Low to moderate certainty evidence suggests that FV does not have significant additional caries-preventive benefit for children (under 8 years old) when provided as an adjunct to daily tooth brushing with RFT (≥ 1,000 ppm). There is insufficient evidence regarding the additional benefit of other PFA interventions.

CLINICAL RELEVANCE

The decision to apply FV to children needs to be made in light of their actual usage of RFT.

TRIAL REGISTRATION

PROSPERO (CRD42020165270).

Clinical Effect of Two Fluoride Varnishes in Caries-Active Preschool Children: A Randomized Controlled Trial

The prevention of dental caries in preschool children is a priority for dental services. The aim of the study was to investigate the caries-preventive effect of 2 fluoride varnishes in caries-active preschool children, and then compare the outcome with a non-varnish control group. After screening, 180 preschool children aged 36-71 months, with at least 1 noncavitated lesion, were enrolled and randomly allocated into 3 parallel groups, namely A: 1.5% ammonium fluoride varnish (Fluor Protector S), B: 5% NaF varnish (Duraphat), and C: professional tooth-cleaning. All children were recalled every third month for intervention and their parents were instructed to have them brush their teeth with a 1,000-ppm fluoride toothpaste twice daily. Caries were recorded at baseline and after 12 months by a calibrated examiner and the incidence was scored on noncavitated (d2) and cavitated (d3) level. We tested differences between the groups with the χ2 and two-sided t tests. One hundred and seventy-two children (95.6%) completed the trial and 56 (32.6%) and 35 (19.2%) developed new d2 and d3 lesions, respectively. Both varnishes reduced the incidence of caries compared with the control group, but there was no significant difference between group A and group B. Compared with group C, the relative risk for developing cavitated lesions was 0.39 (95% CI 0.22-0.62) in group A and 0.26 (95% CI 0.14-0.50) in group B. The total prevented fraction (Δd2d3mft) for group A and group B was 19.9 and 22.5% (p < 0.05), respectively. No adverse effects were observed or reported during the study period. In conclusion, the 2 fluoride varnishes demonstrated an equal capacity to reduce the incidence of caries in caries-active preschool children over a 12-month period in comparison with a control group.

Systematic Review of Intervention Studies Aiming at Reducing Inequality in Dental Caries among Children

(1) Background: The objective is to systematically review the evidence on intervention programs aiming at reducing inequality in dental caries among children. (2) Methods: Two independent investigators searched MEDLINE, Cochrane library, and Ovid up to December 2020 to identify intervention studies assessing the impact on socioeconomic inequalities in dental caries among children. The interventions included any health promotion/preventive intervention aiming at reducing caries among children across different socioeconomic groups. Comparison groups included children with alternative or no intervention. Cochrane criteria were used to assess interventional studies for risk of bias. (3) Results: After removal of duplicate studies, 1235 articles were retained. Out of 43 relevant papers, 13 articles were identified and used in qualitative synthesis, and reported quantifiable outcomes. The included studies varied in measurements of interventions, sample size, age groups, and follow-up time. Five studies assessed oral health promotion or health-education, four assessed topical fluorides, and four assessed water fluoridation. Interventions targeting the whole population showed a consistent reduction of socioeconomic inequalities in dental caries among children. (4) Conclusion: The quality of included papers was moderate. High heterogeneity did not allow aggregation of the findings. The overall findings suggest that whole population interventions such as water fluoridation are more likely to reduce inequalities in children’s caries than target population and individual interventions.

Evaluation of a national complex oral health improvement programme: a population data linkage cohort study in Scotland

OBJECTIVES

Child dental caries is a global public health challenge with high prevalence and wide inequalities. A complex public health programme (Childsmile) was established. We aimed to evaluate the reach of the programme and its impact on child oral health.

SETTING

Education, health and community settings, Scotland-wide.

INTERVENTIONS

Childsmile (national oral health improvement programme) interventions: nursery-based fluoride varnish applications (FVAs) and supervised daily toothbrushing, community-based Dental Health Support Worker (DHSW) contacts and primary care dental practice visits-delivered to the population via a proportionate universal approach.

PARTICIPANTS

50 379 children (mean age=5.5 years, SD=0.3) attending local authority schools (2014/2015).

DESIGN

Population-based individual child-level data on four Childsmile interventions linked to dental inspection survey data to form a longitudinal cohort. Logistic regression assessed intervention reach and the independent impact of each intervention on caries experience, adjusting for age, sex and area-based Scottish Index of Multiple Deprivation (SIMD).

OUTCOME MEASURES

Reach of the programme is defined as the percentage of children receiving each intervention at least once by SIMD fifth. Obvious dental caries experience (presence/absence) is defined as the presence of decay (into dentine), missing (extracted) due to decay or filled deciduous teeth.

RESULTS

15 032 (29.8%) children had caries experience. The universal interventions had high population reach: nursery toothbrushing (89.1%), dental practice visits (70.5%). The targeted interventions strongly favoured children from the most deprived areas: DHSW contacts (SIMD 1: 29.5% vs SIMD 5: 7.7%), nursery FVAs (SIMD 1: 75.2% vs SIMD 5: 23.2%). Odds of caries experience were markedly lower among children participating in nursery toothbrushing (>3 years, adjusted OR (aOR)=0.60; 95% CI 0.55 to 0.66) and attending dental practice (≥6 visits, aOR=0.55; 95% CI 0.50 to 0.61). The findings were less clear for DHSW contacts. Nursery FVAs were not independently associated with caries experience.

CONCLUSIONS

The universal interventions, nursery toothbrushing and regular dental practice visits were independently and most strongly associated with reduced odds of caries experience in the cohort, with nursery toothbrushing having the greatest impact among children in areas of high deprivation.

Evaluation of a community-based early childhood caries (ECC) intervention in Cambodia

OBJECTIVE

To critically evaluate an early childhood caries (ECC) intervention performed by non-dental primary healthcare providers.

METHODS

This mixed-methods investigation includes data from three sources: (a) a pilot non-randomized controlled trial to examine clinical outcomes at four health centres; (b) stakeholder focus group interviews; and (c) a survey of parents whose children were exposed to the intervention. The pilot study involved four Community Health Centres in rural Cambodia whereby mother-child (6-24 months of age)dyads received oral health education (OHE), toothbrushes, fluoride toothpaste and fluoride varnish on up to six occasions as part of the routine vaccination schedule. Outcomes were as follows: presence of ECC; impacts on oral health-related quality of life (OHRQoL); stakeholder perceptions of intervention delivery; and parental perceptions of fluoride varnish.

RESULTS

Participants in the intervention group had six times lower odds of developing ECC than those in the comparison group after controlling for socio-economic status (OR 0.13). Those in the intervention group also had a large reduction OHRQoL scale scores. Key knowledge and practice gaps were identified among stakeholders. Surveyed parents had favourable views of the fluoride varnish placement by medical professionals, and four out of five stated that they would recommend fluoride varnish for other children. Primary healthcare providers, commune council representatives and community health promoters supported oral health interventions being provided in CHCs.

CONCLUSIONS

OHE and fluoride varnish interventions provided by non-dental primary health workers were feasible and acceptable for stakeholders in a Cambodian setting. The intervention group had lower ECC experience and better OHRQoL at 2 years of age.

Fluoride Varnish in Nursery Schools: A Randomised Controlled Trial – Protecting Teeth @3

Studies suggest that fluoride varnish (FV) application can reduce dental caries in child populations. The multiple-component national child oral health improvement programme in Scotland (Childsmile) includes nursery-based universal supervised toothbrushing and deprivation-targeted FV applications, together with community and dental practice prevention interventions. This trial, a double-blind, two-arm randomised control trial, aimed to assess the effectiveness and cost-effectiveness of the nursery-based FV applications plus treatment-as-usual (TAU) Childsmile programme interventions, compared to TAU Childsmile interventions alone, in children not targeted to receive nursery FV as part of the programme. Participating children in the first year of nursery (aged three), with or without existing caries, were randomised to either FV or TAU and followed up for 24 months until the first year of primary school. Treatments were administered at six-monthly intervals. The primary endpoint was “worsening of d3mft” from baseline to 24 months. Secondary endpoints were worsening of d3mfs, d3t, mt, and ft. Individual record-linkage captured wider programme activities and tertiary endpoints. A total of 1,284 children were randomised, leading to 1,150 evaluable children (n = 577 FV, n = 573 TAU, 10% dropouts). Mean age was 3.5 years, 50% were female (n = 576), 17% had caries at baseline (n = 195), all balanced between the groups. Most children received three/four treatments. Overall, 26.9% (n = 155) had worsened d3mft in the FV group, and 31.6% (n = 181) in the TAU group, with an odds ratio (OR) of 0.80 (0.62–1.03), p = 0.078. The results for worsening of the secondary endpoints were: d3mfs 0.79 (0.61–1.01) p = 0.063, d3t 0.75 (0.57–0.99) p = 0.043, mt 1.34 (0.75–2.39) p = 0.319, and ft 0.77 (0.53–1.14) p = 0.191. We calculated a number needed to treat of 21 and a cost of GBP 686 to prevent a single worsening of d3mft. There was a modest non-significant reduction in the worsening of d3mft in the nursery FV group compared to TAU, suggesting that this intervention is unlikely to represent an effective or cost-effective addition to the population oral health improvement programme.

Risk communication in the context of clinical research

Physicians and dentists usually make clinical decisions and recommendations without a clear understanding of the meaning of the numbers regarding the accuracy of diagnostic tests and the efficacy of treatments. This critical review aimed to identify problems in the communication of diagnostic test accuracy and treatment benefits and to suggest strategies to improve risk communication in these contexts. Most clinical decisions are taken under uncertainty. Health professionals cannot predict the outcome in one individual patient. This uncertainty invites these professionals to make decisions based on heuristics, which gives rise to several cognitive biases. Cognitive biases are automatic and unconscious, so how is it possible to mitigate their undesirable effects on risk interpretation in the context of clinical practice? Some forms of risk communication reinforce cognitive bias, while others weaken them. Maybe one of the most difficult obstacles to overcome is the difficulty to think with numbers. This difficulty probably arises from a mismatch of ancestral adaptations of the brain having to deal with modern environments, which are quite different from the ancestral ones. There are two quite common, but bad, forms of risk communication: the conditional probability and the relative risk reduction or efficacy. People, including physicians and dentists, are confused with this kind of information. The main methods discovered so far to facilitate a clearer understanding are to emphasize the base rates of the events and to use absolute numbers, that is to use natural frequencies, instead of percentages and conditional probabilities.

Do Oral Health Services in Medical Offices Replace Pediatric Dental Visits?

In the United States, state Medicaid programs pay for medical and dental care for children from low-income families and support nondental primary care providers delivering preventive oral health services (POHS) to young children in medical offices ("medical POHS"). Despite the potential of these policies to expand access to care, there is concern that they may replace dental visits with medical POHS. Using Medicaid claims from 38 states from 2006 to 2014, we conducted a repeated cross-sectional study and used linear probability regression to estimate the association between the annual proportion of children in a county receiving medical POHS and the probability that a child received 1) dental POHS and 2) a dental visit in a given year. Models included county and year fixed effects and controlled for child- and county-level factors, and standard errors were clustered at the state level. In a weighted population of 45.1 million child-years (age, 6 mo to <6 y), we found no significant nor substantively important association between the proportion of children in a county receiving medical POHS and the probability that a child received dental POHS or a dental visit. Additionally, we found an almost zero probability (<0.001) that the reduction in dental POHS was at least as large as the expansion in medical POHS (full substitution) and a 0.50 probability that increased medical POHS was associated with an increase in dental POHS of at least 6.6% of the expansion of medical POHS. Results were similar when receipt of dental visits was examined. This study failed to find evidence that medical POHS replaced dental visits for young children enrolled in Medicaid and, in fact, offers evidence that increased medical POHS was associated with increased utilization of dental care. Given lower-than-desired rates of dental visits for this population, delivery of medical POHS should be expanded.

Exploring the cost-effectiveness of child dental caries prevention programmes. Are we comparing apples and oranges?

Data sources The following seven databases were searched: PubMed, EMBASE, DARE, NHSEED, HTA, Cost-Effectiveness Analysis Registry and Paediatric Economic Database Evaluation (PEDE).Study selection The review included trial and model-based economic evaluation studies and the participants included children aged from 0 to 12 years old who were healthy except for having dental caries. Studies of mixed populations of parents and children were included where the data for children were presented separately.The interventions included were:• Community-based oral-health education/training programs related to healthy oral habits.• Screening of children's teeth.• Supervised toothbrushing technique through the provision of toothbrushes, an appropriate amount of fluoride toothpaste, and topical fluoride.• Advice on dietary control, such as limitation of sugar or carbohydrates consumption, and enhanced fortified nutrition with an appropriate amount of calcium intake.• The comparators were situations where the populations were the same as the test group, but were receiving no intervention, or a dissimilar one .The interventions were oral-health promotion programs (OHPPs) implemented by oral-health professionals in the contexts of home visits, telephone calls, healthcare centres and primary schools.The outcome measures were reductions in the Decayed, Missing, Filled Teeth (DMFT) index for permanent teeth or (dmft) index for deciduous teeth among children and OHPP cost, incremental cost (difference between mean costs of intervention and mean costs of the comparator), and cost-effectiveness analysis (CEA).Data extraction and synthesis The title, abstract and full text of each study were screened. During the first phase screening of titles and abstracts, irrelevant records were removed. The exclusion criteria were: participant with health-related diseases or aged older than 12 years; interventions other than OHPP (such as implant dentistry or other invasive-dentistry programs); other economic-evaluation outcomes such as cost-benefit, cost-utility or cost-minimisation; authors' opinion (unoriginal records); reviews; and study language other than English. The second-phase screening assessed full texts of the articles using the same eligibility criteria. The risk of bias was assessed using the Drummond 10-item Checklist. Meta-analysis: The costs were converted to 2015 USA dollars. Data analysis was performed through dichotomous outcomes such as the number of children in the intervention and in the control group, the DMFT index in children, and the OHPP cost. Odds ratios (ORs), effect sizes with 95% confidence interval (CIs) and study weights were estimated from random effects analysis. Forest plots were constructed for each outcome, and chi-square tests used to assess homogeneity, where a p-value of less than 0.1 indicated statistically significant heterogeneity. An I2 test was used to quantify inconsistencies between studies as the percentage of variation across studies. Data synthesis was carried out using narrative demonstration, with a summary of the characteristics of each included study. For quantitative synthesis, a summary of the combined estimation related to the OHPP effect was measured. Three types of subgroup analysis were performed: by the age of the children (age under or equal to 6 years, and age 6-12 years), by publication year (studies published in the last five years, and earlier published studies) and by the country of the study. Egger's regression test and a funnel plot were used to assess and demonstrate publication bias. Publication bias was considered present if the p-value of the Egger test was more than 0.05.Results 19 full texts were included into qualitative synthesis and eight articles used in quantitative synthesis. Qualitative synthesis results: With regards to the country of origin, 32% of the studies were conducted in the United Kingdom (n = 6), 26% in Australia (n = 5), 16% in the United States (n = 3). There was also one study from each of the following countries Finland, Ireland, Japan, Nigeria and Singapore. Fifty-two percent (n = 10) were model-based economic evaluation studies and 47% (n = 9) were trial-based economic evaluations. The population of 14 studies were younger than six years of age, while in four studies the children were over the age of six years. In one paper the age of the children was not clearly stated. Just under a half of the papers (47%) were published in the last five years.The majority of the studies had a low risk of bias (n = 12, 63%) and seven (37%) had a moderate risk of bias. Various outcome measures were used in the included studies: DMFT, average number of dental visits, number of prevented caries teeth, average number of cavity-free months, probability of less cost, caries prevalence, number of specific OHPP visits, quality-adjusted life year, cost-effectiveness ratio, and percentages of not having debris.Quantitative synthesis results: The overall pooled impact of OHPPs showed that children with tooth decay had 81% lower odds of participating in OHPP (95% CI 61-90%, I2: 98.5%, p = 0) with considerable heterogeneity among studies. OHPPs were successful in reducing financial costs in 97 out of 100 OHPPs (95% CI 89-99%, I2: 99%, p = 0) with considerable heterogeneity among studies. The studies with participants under the age of six years old weighted 71% with an OR of 0.14 (95% CI, 0.05-0.39, I2: 99%). These children had the highest benefit of OHPPs to lower DMFT/S. The studies reporting children aged six years and over weighted 29% with an OR of 0.29 (95% CI, 0.08-1.01, I2: 99%), and these children had no benefit from OHPPs in lowering DMFT/S. Studies with under-six-year-old participants had an OR of 0.07 (95% CI, 0.02-0.32) revealing no cost-effectiveness effect to reduce OHPP incremental cost, whereas studies reporting children aged six years and older had an OR of 0.0 (95% CI, 0.00-48,704.6). The authors concluded that OHPPs involving the later (older) children were cost-effective in reducing the OHPPs' incremental cost.Conclusions A comprehensive analysis of the OHPPs confirmed that DMFT could be reduced, hence, lowering the financial burden of dental-care treatment. More effort is needed to manage the allocation of scarce resources, taking into account the economic impact of dental caries on healthcare systems. More studies on caries-prevention programmes among young children in high-, middle- and low-income countries are needed, in order to assess the clinical and financial effectiveness.

Addition of Povidone-Iodine to Fluoride Varnish for Dental Caries: A Randomized Clinical Trial

INTRODUCTION

Dental caries is the most common chronic childhood disease. Products of metabolism by bacteria populating the tooth surface induce development and progression of cavities.

OBJECTIVES

We sought to determine whether a polyvinylpyrrolidone-iodine (PVP-I; povidone-iodine) and NaF topical varnish was superior to one containing only NaF in prevention of new dental caries lesions in a single-center randomized active-controlled trial based on a double-blind, parallel-group design.

METHODS

The site was Pohnpei State, Federated States of Micronesia. The study population was healthy children 49 to 84 mo old who were enrolled in early childhood education: 284 were randomized (1:1 allocation), and 273 were included in year 1 analysis and 262 in year 2. The test varnish contained 10% PVP-I and 5.0% NaF. The comparator contained only 5.0% NaF but was otherwise identical. Varnishes were applied every 3 mo during 2 y. The primary outcome was the surface-level primary molar caries lesion increment (d_2-4mfs) at 2 y. Caries lesion increments from baseline to year 1 and year 2 were compared between conditions with log-linear regression, adjusting for age and sex and whether the tooth was sound at baseline (free of caries lesions).

RESULTS

At year 1, the caries lesion increment for primary molars sound at baseline was 0.9 surfaces (SD = 1.5) for the test varnish versus 1.8 (SD = 2.2) for the comparator varnish with fluoride alone (adjusted rate ratio, 0.50; 95% CI, 0.31 to 0.81; P = .005). At year 2, the caries lesion increment for primary molars sound at baseline was 2.3 surfaces (SD = 2.8) for the test varnish as compared with 3.3 (SD = 2.7) for the comparator (adjusted rate ratio, 0.74; 95% CI, 0.52 to 1.03; P = .073). Teeth that were already cavitated at baseline did not show a preventive effect. There were no harms.

CONCLUSIONS

A dental varnish containing PVP-I and NaF is effective in the primary prevention of cavities in the primary dentition (NCT03082196).

KNOWLEDGE TRANSFER STATEMENT

This study demonstrates that periodic application of a varnish containing NaF and PVP-I is effective in prevention of caries lesions and useful in assessing the potential of combined treatment.

A randomized clinical trial to arrest dentin caries in young children using silver diamine fluoride

OBJECTIVES

The study aimed to compare the effectiveness of 38% silver diamine fluoride (SDF) solution, and 5% sodium fluoride (NaF) varnish applied semiannually in arresting dentin caries in young children with high caries risk.

METHODS

Children aged 1-3 years who had at least one active dentin carious lesion were randomly allocated into 2 groups as follows: Group 1 = 38% SDF (Topamine), and Group 2 = 5% NaF varnish (Duraphat). Both agents were applied every 6 months onto the carious surface. Lesion activity was assessed by the visual-tactile examination. Baseline and follow-up examinations were conducted by the same examiner. The children's demographic background, oral health-related habits, and oral hygiene practices, as well as parental satisfaction with children's dental appearance were collected at baseline and the 12-month follow-up.

RESULTS

At baseline, 153 and 149 children were recruited in Group 1 and Group 2, respectively. The mean dmfs scores in Groups 1 and 2 were 8.89 and 9.79, respectively. After 12 months, 87.1% remained in the study. The caries arrest rate of Group 1 (35.7%) was significantly higher than that of Group 2 (20.9%) (p < 0.001). The results of the multilevel logistic regression analysis confirmed that the treatment in Group 1 was more effective in arresting dentin carious lesions than that of Group 2 (OR = 2.04; 95% CI, 1.41-2.96). The presence of plaque on caries lesions, tooth type, tooth surface type, frequency of milk feeding, snack taking, and family income influenced on caries activity. Regardless of the intervention groups, there were no differences in parental satisfaction with on the child's dental appearance before and after receiving the intervention.

CONCLUSION

Based on the 12-month results, 38% SDF is more effective than 5% NaF varnish in arresting dentin carious lesions in young children. SDF has no negative impact on parental satisfaction with the child's dental appearance.

CLINICAL SIGNIFICANCE

To control dentin carious lesions in young children with high caries risk, 38% SDF is more effective than 5% NaF varnish.

Impact of a Medicaid policy on preventive oral health services for children with intellectual disabilities, developmental disabilities, or both

BACKGROUND

Integrating preventive oral health services (POHS) into medical offices may ease access to care for children with intellectual and developmental disabilities (IDD). The authors examined the impact of state policies allowing delivery of POHS in medical offices on receipt of POHS among Medicaid enrollees with IDD.

METHODS

The authors used 2006 through 2014 Medicaid data for children with IDD aged 6 months through 5 years from 38 states. IDD were defined using 14 condition codes from Centers for Medicare & Medicaid Services Chronic Conditions Data Warehouse. The length of the state's medical POHS policy (no policy, < 1 year, 1 year, 2 years, 3 years, or ≥ 4 years) was interacted with an indicator that the child was younger than 3 years. The authors used logistic regression models to estimate the likelihood that a child received POHS in a medical office or in a medical or dental office in a given year.

RESULTS

Among 447,918 children with IDD, 1.6% received POHS in medical offices. Children younger than 3 years in states with longer-enacted policies had higher rates of receiving POHS. For example, the predicted probability of receiving POHS was 40.6% (95% confidence interval, 36.3% to 44.9%) for children younger than 3 years in states with a medical POHS policy for more than 4 years compared with 30.6% (95% confidence interval, 27.8% to 33.5%) for children in states without a policy.

CONCLUSIONS

State Medicaid policies allowing delivery of POHS in medical offices increased receipt of POHS among Medicaid-enrolled children with IDD who were younger than 3 years.

PRACTICAL IMPLICATIONS

Few children with IDD receive POHS in any setting. Efforts are needed to reduce barriers to POHS for publicly insured children with IDD.