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

Patterns of fluoride intake from 6 to 17 years of age: The Iowa Fluoride Study

OBJECTIVES

This article reports on estimated daily fluoride intake from water, other beverages and selected foods, dentifrice, and dietary fluoride supplements by both individual sources, and all sources combined, among 787 children participating in the Iowa Fluoride Study (IFS) from 6 to 17 years of age.

METHODS

Total daily fluoride intake (mg F) and fluoride intake per kilogram bodyweight (mg F/kg bw) were estimated using responses to questionnaires sent every 3-6 months. Dietary assessments included frequencies and amounts of beverage intake for the previous week from water, milk, ready-to-drink beverages, beverages made by adding water to concentrate or powder, and selected foods with substantial water content. Descriptive statistics and bivariate and multivariable analyses with linear mixed models were used to assess associations with each of mg F and mg F/kg bw.

RESULTS

Mean combined dietary fluoride (mg F) from all sources examined in the study increased slightly with age, whereas the fluoride intake per kg bw decreased with age. Age, sex, and socioeconomic status were significantly associated with fluoride intake (mg F and mg F/kg bw). Each year increase in age was associated with a 0.02-mg increase in fluoride consumption, on average, after adjusting for the effects of covariates.

CONCLUSIONS

Daily mean fluoride intakes from single and combined sources were relatively stable, while the intake of fluoride per kg bw decreased from 6 to 17 years of age. Fluoridated water was the major source of ingested fluoride, contributing over 50% of total daily intake at all ages.

Drinking Water From Private Wells and Risks to Children

Drinking water for approximately 23 million US households is obtained from private wells. These wells can become contaminated by pollutant chemicals or pathogenic organisms, leading to significant illness. Although the US Environmental Protection Agency and all states offer guidance for construction, maintenance, and testing of private wells, most states only regulate the construction of new private water wells. With a few exceptions, there is little regulation after construction. Well owners are responsible for their own wells. Children may also drink well water at child care or when traveling. Illness resulting from children’s ingestion of contaminated water can be severe. This report reviews relevant aspects of groundwater and wells; describes the common chemical and microbiologic contaminants; gives an algorithm with recommendations for inspection, testing, and remediation for wells providing drinking water for children; and provides references and Internet resources for more information.

Preventive Oral Health in Pediatric Primary Care

Oral health is an integral part of every child's overall wellness and affects their development, family, and social life, as well as school performance; it should be addressed at every well-child visit. Tooth decay continues to be the most prevalent yet preventable chronic disease of childhood; it leads to unnecessary pain, infections, poor academic performance, and frequent school absences and adds an unnecessary financial burden to the health care system. Despite improvements in oral health, disparities continue to exist for children from minority backgrounds and lower socioeconomic status. As primary care providers for children, it is important to understand factors that lead to oral disease and be able to anticipate, treat, and, most important, prevent oral disease in children early in their development. [Pediatr Ann. 2022;51(12):e474-e479.].

Fluoridated milk enhances the mineral density of artificial proximal carious lesions in situ

OBJECTIVE

To compare the mineral density (MD) of non-fluoridated-milk (non-F-milk), fluoridated-milk (F-milk), adjunctive to 1000-ppm-fluoride dentifrice (FD), and 1000-ppm-FD alone of proximal artificial enamel carious lesions (AECL) in high caries-risk patients.

MATERIALS AND METHODS

This double-blind, cross-over in situ study comprised seven high caries-risk volunteers. Orthodontic brackets with one slab of AECL were fixed randomly to each volunteer per phase. The study comprised three experimental periods with a 7-d wash-out period using FD between sessions; (1) A four-week tooth brushing with FD 2×/day by all subjects as a control. The participants were then randomly allocated to (2) drinking 2.5-ppm-F-milk 1×/day or (3) non-F-milk 1×/day, adjunctive to tooth-brushing with FD for 4-weeks. The subjects crossed over from each type of milk and continued the same protocol for another four weeks. After each phase, the MD of each specimen was analyzed using micro-computed tomography (Micro-CT).

RESULTS

The baseline MD was not significantly differences (p = .653). When brushing with FD and drinking F-milk, the MD gain was significantly higher (11.68 ± 2.89%) compared with brushing with FD and drinking non-F-milk (4.59 ± 1.78%) (p = .003) or brushing with FD alone (5.30 ± 2.10%) (p = .003).

CONCLUSIONS

F-milk adjunctive to FD significantly increased MD gain compared with non-F-milk + FD or FD alone.

Steric hindrance effect on the excited-state proton transfer process: TDDFT study on the fluorescent sensing mechanism of a fluoride sensor

An understanding of the excited-state process and the sensing mechanism for specific anions can be helpful for the design and synthesis of fluorescent sensors in analytical chemistry and biotechnology. Here, we theoretically investigated the fluorescent response mechanism of a reported acylhydrazone-based fluorescent sensor (Soft Matter, 2019, 15, 6690) for fluoride recognition using the time-dependent density functional theory approach. At the M06/TZVP/SCM level, the vertical excitation energies, which were calculated based on the ground state and first singlet-state geometries of the sensor molecule, agreed well with the experimental ultraviolet-visible and fluorescence spectra. Therefore, the time-dependent density functional theory method was considered reasonable and effective. According to the frontier orbital analysis and an excited-state potential energy scan, we proposed an excited-state proton transfer mechanism for the sensor-fluorine complex, where the steric hindrance leads to a high potential barrier. The excited-state proton transfer process facilitates sensor molecule deprotonation, alleviates its steric hindrance effect and expands its conjugated system. As a result, the fluorescence emission band of the sensor molecule was red-shifted significantly with the addition of fluoride anion. Based on this fluorescence difference, the sensor could be used for fluoride anion identification. This work provides a strategy to study sensor-analyte interactions in the excited state and offers an approach to tune the fluorescence emission wavelength of sensor molecules in anionic environments.

Fluoride Prescribing Behaviors for Medicaid-Enrolled Children in Oregon

INTRODUCTION

This study aims to examine physician and dentist fluoride prescription patterns and identify the factors associated with fluoride prescriptions for Medicaid-enrolled children. The hypothesis is that dentists will be the primary prescribers of fluoride and that caries risk factors will be associated with fluoride prescriptions.

METHODS

Data were analyzed for Oregon children aged 0-17 years enrolled in Medicaid for ≥300 days in both 2016 and 2017. The outcome variable was receiving a fluoride prescription in 2017. A 2-tailed chi-square test was used to assess fluoride prescribing differences between physicians and dentists. Multivariable logistic regression models were used to examine the likelihood of receiving a fluoride prescription in 2017 and to generate ORs. Model covariates included child's age, sex, race, ethnicity, Medicaid plan type, previous fluoride prescription, previous restorative dental treatment, and water fluoridation status.

RESULTS

Of 200,169 Medicaid-enrolled children, 6.7% (n=13,337) received fluoride prescriptions. Physicians were >3 times as likely to prescribe fluoride as dentists (73.4% vs 23.0%, p<0.001). Children with a history of fluoride prescriptions (OR=14.30, p<0.001) and any restorative dental treatment (OR=1.58, p<0.001) were significantly more likely to receive a fluoride prescription, whereas children living in areas with water fluoridation were significantly less likely (OR=0.50, p=0.01).

CONCLUSIONS

Physicians play an important role in prescribing fluoride to Medicaid-enrolled children, especially those at increased dental caries risk. Additional research is needed on strategies to ensure that all high-risk children have an opportunity to benefit from prescription fluoride.

Review of Professionally Applied Fluorides for Preventing Dental Caries in Children and Adolescents

This review aims to evaluate the effectiveness of professional topical fluoride application on the prevention of dental caries in primary and permanent dentition. A web search was conducted for English papers published from 2000 to 2020, using various digital resources (Pubmed, Google Scholar, Cochrane Library, and ResearchGate). The keywords were “professionally applied fluoride”, “fluoride gel”, “fluoride varnish”, “fluoride foam”, “fluoride mouthrinses”, and “non-cavitated caries lesions”. Inclusion criteria: (a) participants: children and adolescents, treated in a dental care setting; (b) intervention: professionally applied fluorides (gel, varnish, foam, mouthrinse); (c) comparator: no professional treatment or other preventive treatments; (d) outcomes: clinical effectiveness (e.g., caries reduction, tooth remineralization); (e) study design: randomized controlled trials, systematic reviews, meta-analyses; (f) publication period: 1 January 2000–31 December 2021. Clinical studies about home-use fluoride products, discussion papers, in-vitro studies, case reports, non-English articles, and studies with unclear methodology were excluded. Topical fluoride applications are indicated for patients with active smooth surface caries and for patients in high caries risk groups. Both APF gel and fluoride varnish are effective and can be recommended for caries prevention in primary and permanent teeth. For children under the age of 6, only 2.26% fluoride varnish is recommended.

Predictors of Plasma Fluoride Concentrations in Children and Adolescents

Despite increasing concerns about neurotoxicity of fluoride in children, sources of fluoride exposure apart from municipal water fluoridation are poorly understood. We aimed to describe the associations of demographics, drinking water characteristics, diet, and oral health behaviors with plasma fluoride concentrations in U.S. children. We used data from 3928 6–19-year-olds from the 2013–2016 National Health and Nutrition Examination Survey. We used a 24-h dietary recall to estimate recent consumption of fluoridated tap water and select foods. We estimated the associations of fluoridated tap water, time of last dental visit, use of toothpaste, and frequency of daily tooth brushing with plasma fluoride concentrations. The participants who consumed fluoridated (≥0.7 mg/L) tap water (n = 560, 16%) versus those who did not had 36% (95% CI: 22, 51) higher plasma fluoride. Children who drank black or green tea (n = 503, 13%) had 42% higher plasma fluoride concentrations (95% CI: 27, 58) than non-tea drinkers. The intake of other foods and oral health behaviors were not associated with plasma fluoride concentrations. The consumption of fluoridated tap water and tea substantially increases plasma fluoride concentrations in children. Quantifying the contribution of diet and other sources of fluoride is critical to establishing safe target levels for municipal water fluoridation.

Fluoride Use in Caries Prevention in the Primary Care Setting

Dental caries remains the most common chronic disease of childhood in the United States. Caries is a largely preventable condition, and fluoride has proven effectiveness in caries prevention. This clinical report aims to clarify the use of available fluoride modalities for caries prevention in the primary care setting and to assist pediatricians in using fluoride to achieve maximum protection against dental caries, while minimizing the likelihood of enamel fluorosis. Fluoride varnish application is now considered the standard of care in pediatric primary care. This report highlights administration, billing, and payment information regarding the fluoride varnish procedure.

Dental Decision Simulation (DDSim): Development of a virtual training environment

PURPOSE

Case-based simulations are powerful training tools that can enhance learning and drive behavior change. This is an overview of the design/development of Dental Decision Simulation (DDSim), a web-based simulation of an electronic dental record (EDR). The purpose was to use DDSim to train dentists to make evidence-based treatment planning decisions consistent with current evidence. This simulated EDR provides case-based information in support of a set of defined evidence-based learning objectives.

METHODS

The development of this complex simulation model required coordinated efforts to create several components: identify behavior changes, case authoring mechanism, create virtual patient visits, require users to make treatment plan decisions related to learning objectives, and a feedback mechanism to help users recognize departures from those learning objectives. This simulation was evaluated in a 2-arm, clinic-randomized, controlled pilot study examining the extent to which DDSim changed dentists' planned treatment to conform to evidence-based treatment guidelines relative to change in dentists not exposed to DDSim. Outcomes were measured by comparing preintervention and postintervention patient EDR treatment data.

RESULTS

Changes in behavior over time did not favor intervention or control clinics.

CONCLUSION

DDSim provides a standardized learning platform that cannot be achieved through the use of live patients. Both live patients and case-based simulations can be used to transfer knowledge and skill development. DDSim offers the advantage of providing a platform for developing treatment planning skills in a low-risk environment. However, further research examining behavior change is needed.

Periodontal and dental conditions of a school population in a volcanic region of Tanzania with highly fluoridated community drinking water

Introduction

Dental fluorosis is endemic in the Rift Valley in Africa, especially around volcanic areas, due to the high fluoride content in daily drinking water.

Objective

This study evaluates the oral health status and types of occlusion in a school population, and to assess the possible association between dental fluorosis and other pathologies such as decay, gingivitis and periodontitis.

Material and methods

An observational study of 581 individuals recruited from a public secondary school in Arusha, Northern Tanzania was undertaken. The indices used were: the Silness & Löe Plaque Index, the Community Periodontal Index and the Decayed/Missing/Filled index. Descriptive statistical analyses were performed and a chi-square test was used to assess the associations between independent variables.

Results

Almost all the school children evaluated (96.73%) presented Angle class I dental occlusion, and 75.22% presented some degree of dental fluorosis. Most of the population (511, 87.95%) showed bleeding on probing. A moderate/high degree of some dental pathology (DMF score) was recorded in 14.46%. The association between dental fluorosis, gingival bleeding and tooth decay indicated a higher concentration of pathology in groups with more severe fluorosis (p<0.05).

Conclusion

In this large population sample, both tooth decay and gingivitis were significantly associated with moderate or severe dental fluorosis.

Filled dietary fluoride supplement prescriptions for Medicaid-enrolled children living in states with high and low water fluoridation coverage

BACKGROUND

Although dietary fluoride (F) supplements (DFS) are recommended for children who use F-deficient drinking water, no studies have examined filled DFS prescriptions across multiple states to examine the dosage consistency with current recommendations or prescription length.

METHODS

This sequential cross-sectional analysis used Medicaid claims data for children aged 0.5 through 16 years who in 2011 lived in the 6 states with the lowest and the highest fluoridation coverage (≤ 34% and ≥ 95% of the public water system population fluoridated, respectively). For 2011, the authors calculated the mean percentage of children with filled DFS prescriptions and the change since 2000 across states with high and low fluoridation coverage, the percentage of children with filled DFS prescriptions containing F dosage consistent with current recommendations, and filled DFS prescription length and cost across states.

RESULTS

In states with high fluoridation coverage, the mean percentage of children with a filled prescription was < 1% in both years; in states with low fluoridation coverage, this value increased from 0.9% to 10.3%, the highest increase (16.4 percentage points) since 2000 among children aged 0.5 through 2 years. The average prescription length was 72 days. Across states, the mean costs per child prescribed supplements and per enrollee were $17.60 and $1.05, respectively.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Filled prescriptions largely followed current recommendations but reached only a small percentage of children in low-coverage states. The short prescription length indicated limited exposure for caries prevention. Results from these states suggest more children could have longer exposure to the caries-preventive benefits of F at a similar cost with water fluoridation as with DFS.

Fluoride Revolution and Dental Caries: Evolution of Policies for Global Use

Epidemiological studies over 70 y ago provided the basis for the use of fluoride in caries prevention. They revealed the clear relation between water fluoride concentration, and therefore fluoride exposure, and prevalence and severity of dental fluorosis and dental caries. After successful trials, programs for water fluoridation were introduced, and industry developed effective fluoride-containing toothpastes and other fluoride vehicles. Reductions in caries experience were recorded in many countries, attributable to the widespread use of fluoride. This is a considerable success story; oral health for many was radically improved. While previously, water had been the only significant source of fluoride, now there are many, and this led to an increase in the occurrence of dental fluorosis. Risks identified for dental fluorosis were ingestion of fluoride-containing toothpaste, water fluoridation, fluoride tablets (which were sometimes ingested in areas with water fluoridation), and infant formula feeds. Policies were introduced to reduce excessive fluoride exposure during the period of tooth development, and these were successful in reducing dental fluorosis without compromising caries prevention. There is now a much better understanding of the public perception of dental fluorosis, with mild fluorosis being of no aesthetic concern. The advantages of water fluoridation are that it provides substantial lifelong caries prevention, is economic, and reduces health inequalities: it reaches a substantial number of people worldwide. Fluoride-containing toothpastes are by far the most important way of delivering the beneficial effect of fluoride worldwide. The preventive effects of conjoint exposure (e.g., use of fluoride toothpaste in a fluoridated area) are additive. The World Health Organization has informed member states of the benefits of the appropriate use of fluoride. Many countries have policies to maximize the benefits of fluoride, but many have yet to do so.

Fluoride Use in Health Care Settings: Association with Children's Caries Risk

Expanded partnership with the medical community is an important strategy for reducing dental caries disparities. The purpose of this study was to assess the relationship between fluoride (F) "in office" (drops/tablets and/or varnish), as prescribed or applied by a health care professional by age 1 y, and 1) caries development and 2) presence of other caries risk factors or mediators (e.g., socioeconomic status). Child-primary caregiver (PCG) pairs ( N = 1,325) were recruited in Indiana, Iowa, and North Carolina as part of a longitudinal cohort study to validate a caries risk tool for primary health care settings. PCGs completed a caries risk questionnaire, while children received caries examinations per the criteria of the International Caries Detection and Assessment System at ages 1, 2.5, and 4 y. Baseline responses regarding children's history of F in office were tested for association with other caries risk variables and caries experience at ages 2.5 and 4 y via generalized estimating equation models applied to logistic regression. The sample was 48% female, and many children (61%) were Medicaid enrolled. The prevalence of cavitated caries lesions increased from 7% at age 2.5 y to 25% by age 4 y. Children who received F in office were likely deemed at higher caries risk and indeed were significantly ( P < 0.01) more likely to develop cavitated caries lesions by ages 2.5 and 4 y, even after F application (odds ratios: 3.5 and 2.3, respectively). Factors significantly associated with receiving F included the following: child being Medicaid enrolled, not having an employed adult in the household, child and PCG often consuming sugary drinks and snacks, and PCG having recent caries experience. Increased F in office from a health care provider by age 1 y was associated with known caries risk factors. Most (69%) children had never been to the dentist, suggesting that risk factors could be alerting medical providers and/or parents, thereby affecting in-office F recommendations. Differences among states could also be related to state-specific F-varnish reimbursement policies (ClinicalTrials.gov NCT01707797).

Consequences of community water fluoridation cessation for Medicaid-eligible children and adolescents in Juneau, Alaska

BACKGROUND

The general aim of this research was to determine whether cessation of community water fluoridation (CWF) increased oral health disparities, as measured by dental caries procedures and restoration costs for children and adolescents.

METHODS

The analysis was based on all Medicaid dental claims records of 0- to 18-year-old patients residing in zip code 99801 (Juneau, Alaska) during an optimal CWF year (2003, n = 853) compared to all claims for the same age group from 2012 (n = 1052), five years after cessation of CWF. A bivariate analysis (Mann-Whitney U test) of the mean number of caries procedures performed per client was conducted in the study groups under both independent CWF conditions. Furthermore, logistic regression was performed using the dependent variables of caries procedures and the cost of caries-related procedures, with adjustments for CWF group, gender, and race.

RESULTS

The statistically significant results included a higher mean number of caries-related procedures among 0- to 18-year-old and < 7-year-old patients in the suboptimal CWF group (2.35 vs. 2.02, p < 0.001; 2.68 vs. 2.01, p = 0.004, respectively). The mean caries-related treatment costs per patient were also significantly higher for all age groups, ranging from a 28 to 111% increase among the suboptimal CWF cohorts after adjusting for inflation. The binary logistic regression analysis results indicated a protective effect of optimal CWF for the 0- to 18-year-old and < 7-year-old age groups (OR = 0.748, 95% CI [0.62, 0.90], p = 0.002; OR = 0.699, 95% CI [0.52, 0.95], p = 0.02, respectively). Additionally, the age group that underwent the most dental caries procedures and incurred the highest caries treatment costs on average were those born after CWF cessation.

CONCLUSIONS

These results expand our understanding of caries epidemiology under CWF cessation conditions and reaffirm that optimal CWF exposure prevents dental decay. These findings can offer fiscal estimates of the cost burden associated with CWF cessation policies and help decision-makers advance oral health, prevent dental caries, and promote equity in oral health outcomes.

The Role of Fluoride in the Prevention of Tooth Decay

Although there are recommendations to prevent tooth decay by other means, this nonsystematic review finds that fluoride is the key to prevention and control of tooth decay. There are multiple fluoride modalities with effectiveness and safety of fluoride depending on dose and concentration. Prevention of tooth decay occurs at the individual level by fluoride use at home and with professional application and at the community level through fluoridation of water or salt.

Topical fluoride use: Knowledge, attitudes and practices of undergraduate dental students of three Dental Colleges in South India

OBJECTIVES

For effective utilisation of topical fluorides in caries prevention, dental professionals should have adequate knowledge regarding its appropriate use. The decision regarding preventive treatments like topical fluorides is influenced by knowledge acquired during undergraduate training. The aim of this study was to assess the knowledge, attitudes and practices of undergraduate dental students in the use of topical fluorides.

METHODOLOGY

A descriptive cross-sectional questionnaire study was conducted from June to August 2015 following ethical clearance. Three willing Dental Colleges from 3 states of South India participated. Information regarding the knowledge, attitudes and practices of students in the use of topical fluorides was collected using a validated questionnaire.

RESULTS

Nine hundred and seventy-two dental students (79.6% females, 20.4% males) participated. Freshers and preclinical batches had poor overall knowledge of fluorides, which did not show substantial improvement by internship. Self-applied topical fluoride use (fluoridated toothpaste) was seen in more than 90% of interns, and majority had "positive fluoride attitude." Having knowledge of topical fluorides and positive attitudes to topical fluorides did not result in "good oral self-care behaviour" nor appropriate clinical use of topical fluorides. Students who used topical fluorides for persons with history of caries had highest odds of brushing twice a day (OR = 2.7, 95% CI = 1.54, 4.12) and a "positive fluoride attitude" (OR = 1.2, 95% CI = 0.21, 1.57).

CONCLUSION

Dental students showed deficiencies in their knowledge and understanding of topical fluorides. Dental education in India needs emphasis on topical fluorides across all years, with a special focus on caries risk-based topical fluoride use.

Change of salivary fluoride level with intake of fluoride releasing lozenges: A pilot study

AIM

Long-term, low-level fluoride concentrations in saliva are highly effective in caries prevention and remineralization. The aim of the present two-phased study was to test whether fluoride-releasing lozenges compared to placebo significantly raise salivary fluoride levels above baseline achieved by 1100 ppm fluoride toothpaste in a double-blind, crossover pilot study.

METHODS

In phase 1, a four-arm crossover basic study, four participants used one dissolvable lozenge with .25, 0.5, 1 or 1.5 mg fluoride for 1 hour. In phase 2, the three-arm crossover main study, 11 participants used three lozenges per day for 1 hour for 1 week, establishing long-term salivary fluoride levels dissolving 0 (control), 0.5 and 1.5 mg fluoride lozenges. Saliva was collected at baseline; during lozenge use; 5, 15, 30, and 60 minutes later; and early the next morning. Salivary fluoride levels were determined by laboratory diffusion analysis.

RESULTS

In phase 1, 5 minutes after using one lozenge, salivary fluoride levels were above baseline (0.03 ppm), reaching 0.13 ± 0.19 ppm for the 0.25 mg and 0.73 ± 0.75 ppm for the 1.5 mg fluoride lozenge, dropping to baseline after 60 minutes. In phase 2, after 1 week use of 0.5 and 1.5 mg lozenges, respectively, for the 0.5 mg lozenge for 15 minutes and the 1.5 mg lozenge 30 minutes after use, the salivary levels were significantly higher than baseline/control (0.02 ppm). During 1-hour lozenge use, fluoride levels >0.1 ppm were consistently achieved.

CONCLUSIONS

Fluoride lozenges achieved elevated salivary fluoride levels during use, but only for short periods after use.

Dental caries prevention in children and adolescents: a systematic quality assessment of clinical practice guidelines

OBJECTIVES

To evaluate the quality of clinical practice guidelines (CPGs) for dental caries prevention in children and adolescents MATERIALS AND METHODS: We performed a systematic search of CPGs on caries preventive measures between 2005 and 2016. We searched MEDLINE, EMBASE, LILACS, TripDatabase, websites of CPG developers, compilers of CPGs, scientific societies and ministries of health. We included CPGs with recommendations on sealants, fluorides and oral hygiene. Three reviewers independently assessed the included CPGs using the AGREE II instrument. We calculated the standardised scores for the six domains and made a final recommendation about each CPG. Also, we calculated the overall agreement among calibrated reviewers with the intraclass correlation coefficient (ICC).

RESULTS

Twenty-two CPGs published were selected from a total of 637 references. Thirteen were in English and nine in Spanish. The overall agreement between reviewers was very good (ICC = 0.90; 95%CI 0.89-0.92). The mean score for each domain was the following: Scope and purpose 89.6 ± 12%; Stakeholder involvement 55.0 ± 15.6%; Rigour of development 64.9 ± 21.2%; Clarity of presentation 84.8 ± 14.1%; Applicability 30.6 ± 31.5% and Editorial independence 59.3 ± 25.5%. Thirteen CPGs (59.1%) were assessed as "recommended", eight (36.4%) "recommended with modifications" and one (4.5%) "not recommended".

CONCLUSIONS

The overall quality of CPGs in caries prevention was moderate. The domains with greater deficiencies were Applicability, Stakeholder involvement and Editorial independence.

CLINICAL RELEVANCE

Clinicians should use the best available CPGs in dental caries prevention to provide optimal oral health care to patients.

Dental caries prevention in children and adolescents: a systematic quality assessment of clinical practice guidelines

OBJECTIVES

To evaluate the quality of clinical practice guidelines (CPGs) for dental caries prevention in children and adolescents MATERIALS AND METHODS: We performed a systematic search of CPGs on caries preventive measures between 2005 and 2016. We searched MEDLINE, EMBASE, LILACS, TripDatabase, websites of CPG developers, compilers of CPGs, scientific societies and ministries of health. We included CPGs with recommendations on sealants, fluorides and oral hygiene. Three reviewers independently assessed the included CPGs using the AGREE II instrument. We calculated the standardised scores for the six domains and made a final recommendation about each CPG. Also, we calculated the overall agreement among calibrated reviewers with the intraclass correlation coefficient (ICC).

RESULTS

Twenty-two CPGs published were selected from a total of 637 references. Thirteen were in English and nine in Spanish. The overall agreement between reviewers was very good (ICC = 0.90; 95%CI 0.89-0.92). The mean score for each domain was the following: Scope and purpose 89.6 ± 12%; Stakeholder involvement 55.0 ± 15.6%; Rigour of development 64.9 ± 21.2%; Clarity of presentation 84.8 ± 14.1%; Applicability 30.6 ± 31.5% and Editorial independence 59.3 ± 25.5%. Thirteen CPGs (59.1%) were assessed as "recommended", eight (36.4%) "recommended with modifications" and one (4.5%) "not recommended".

CONCLUSIONS

The overall quality of CPGs in caries prevention was moderate. The domains with greater deficiencies were Applicability, Stakeholder involvement and Editorial independence.

CLINICAL RELEVANCE

Clinicians should use the best available CPGs in dental caries prevention to provide optimal oral health care to patients.

Fluoride: A review of pre-clinical and clinical studies

Fluoride is ubiquitous in environment and profound in bones, teeth and calcified tissues of human body. Fluoride has been the topic of regular discussion and investigations. Besides its toxicity, fluoride has also been examined for its beneficial effects like prevention and treatment of tooth decay, microbial infection, inflammation, cancer, occurrence of renal stone and many more. Since last many decades, several efforts have been made at pre-clinical and clinical level to understand role of fluoride in biological system. The present review gives a brief account of prevalence, sources of fluoride toxicity and pre-clinical and clinical studies carried out on effects of fluoride in last six decades.

Fluoride supplementation (with tablets, drops, lozenges or chewing gum) in pregnant women for preventing dental caries in the primary teeth of their children

BACKGROUND

Dental caries (tooth decay) is one of the most common chronic childhood diseases. Caries prevalence in most industrialised countries has declined among children over the past few decades. The probable reasons for the decline are the widespread use of fluoride toothpaste, followed by artificial water fluoridation, oral health education and a slight decrease in sugar consumption overall. However, in regions without water fluoridation, fluoride supplementation for pregnant women may be an effective way to increase fluoride intake during pregnancy. If fluoride supplements taken by pregnant women improve neonatal outcomes, pregnant women with no access to a fluoridated drinking water supply can obtain the benefits of systemic fluoridation.

OBJECTIVES

To evaluate the effects of women taking fluoride supplements (tablets, drops, lozenges or chewing gum) compared with no fluoride supplementation during pregnancy to prevent caries in the primary teeth of their children.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 25 January 2017); the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 11) in the Cochrane Library (searched 25 January 2017); MEDLINE Ovid (1946 to 25 January 2017); Embase Ovid (1980 to 25 January 2017); LILACS BIREME Virtual Health Library (Latin American and Caribbean Health Science Information database; 1982 to 25 January 2017); and CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to 25 January 2017). We searched the US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform for ongoing trials to 25 January 2017. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of fluoride supplements (tablets, drops, lozenges or chewing gum) administered to women during pregnancy with the aim of preventing caries in the primary teeth of their children.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the titles and abstracts (when available) of all reports identified through electronic searches. Two review authors independently extracted data and assessed risk of bias, as well as evaluating overall quality of the evidence utilising the GRADE approach. We could not conduct data synthesis as only one study was included in the analysis.

MAIN RESULTS

Only one RCT met the inclusion criteria for this review. This RCT showed no statistical difference on decayed or filled primary tooth surfaces (dfs) and the percentage of children with caries at 3 years (risk ratio (RR) 1.46, 95% confidence interval (CI) 0.75 to 2.85; participants = 938, very low quality of evidence) and 5 years old (RR 0.84, 95% CI 0.53 to 1.33; participants = 798, very low quality of evidence). The incidence of fluorosis at 5 years was similar between the group taking fluoride supplements (tablets) during the last 6 months of pregnancy and the placebo group.

AUTHORS' CONCLUSIONS

There is no evidence that fluoride supplements taken by women during pregnancy are effective in preventing dental caries in their offspring.

Fluoride Supplementation Adherence and Barriers in a Community Without Water Fluoridation

BACKGROUND

To prevent early childhood caries, the American Dental Association recommends oral fluoride supplementation for children in communities lacking water fluoridation who are at high caries risk. However, patient adherence to oral fluoride supplementation has not been studied in this population. This study assessed adherence to oral fluoride and barriers to adherence in a community lacking water fluoridation.

METHODS

A self-administered survey was completed in a systematic sample of 209 parents of children aged 6 months to 4 years, during a primary care visit in an urban academic medical center. Participants reported frequency of administering oral fluoride to their children, as well as agreement or disagreement with proposed barriers to supplementation. Bivariate and multivariate analyses were used to assess adherence with oral supplementation and the association of barriers to supplementation and child receipt of fluoride on the day before.

RESULTS

More than half of parents either had not or did not know if their child had received fluoride on the day before. Approximately 1 in 4 of parents had given fluoride in 0 of the previous 7 days. Difficulty remembering to give fluoride and agreeing that the child does not need extra fluoride were associated with not receiving fluoride on the day before.

CONCLUSIONS

Adherence to oral fluoride supplementation in the primary care setting is low. Difficulty remembering to give fluoride daily is the greatest barrier to adherence. Further research on interventions to reduce common barriers is needed to increase fluoride administration and reduce early childhood caries in communities lacking water fluoridation.

FT-Raman spectroscopic characterization of enamel surfaces irradiated with Nd:YAG and Er:YAG lasers

Background. Despite recent advances in dental caries prevention, caries is common and remains a serious health problem. Laser irradiation is one of the most common methods in preventive measures in recent years. Raman spectroscopy technique is utilized to study the microcrystalline structure of dental enamel. In this study, FT-Raman spectroscopy was used to evaluate chemical changes in enamel structure irradiated with Nd:YAG and Er:YAG lasers.

Methods. We used 15 freshly-extracted, non-carious, human molars that were treated as follows: No treatment was carried out in group A (control group); Group B was irradiated with Er:YAG laser for 10 seconds under air and water spray; and Group C was irradiated with Nd:YAG laser for 10 seconds under air and water spray. After treatment, the samples were analyzed by FT-Raman spectroscopy.

Results. The carbonate content evaluation with regard to the integrated area under the curve (1065/960 cm^–1) exhibited a significant reduction in its ratio in groups B and C. The organic content (2935/960 cm^-1) area exhibited a significant decrease after laser irradiation in group B and C.

Conclusion. The results showed that the mineral and organic matrices of enamel structure were affected by laser irradiation; therefore, it might be a suitable method for caries prevention.

Does early establishment of favorable oral health behavior influence caries experience at age 5 years?

OBJECTIVE

The purpose was to study associations between tooth brushing frequency, use of fluoride lozenges and consumption of sugary drinks at 1.5 years of age and having caries experience at 5 years of age.

METHODS

This study was based on data from the Norwegian Mother and Child Cohort Study conducted by the Norwegian Institute of Public Health and by the Public Dental Services. A total of 1095 children were followed from pregnancy to the age of 5 years. Questionnaires regarding oral health behavior were completed by the parents at 1.5 and 5 years of age. Clinical and radiographic examination of the children was performed at the age of 5 years.

RESULTS

In multiple logistic regression, having caries experience at 5 years of age was associated with; at 1.5 years of age having the teeth brushed less than twice daily (OR = 2.1, CI = 1.3-3.6) and being offered sugary drinks at least once a week (OR = 1.8, CI = 1.1-2.9) when controlled for family characteristics and oral health behavior at 5 years of age.

CONCLUSIONS

Tooth brushing frequency and consumption of sugary drinks in early childhood were related to caries development during pre-school age, independent of family characteristics and oral health behavior at 5 years of age. The results indicate that early established habits regarding tooth brushing and consumption of sugary drinks have long-term effects on caries development. Parents encountering difficulties in establishing favorable oral health behavior in children's first years of life should receive special attention from health personnel.

Maintaining and improving the oral health of young children

Oral health is an integral part of the overall health of children. Dental caries is a common and chronic disease process with significant short- and long-term consequences. The prevalence of dental caries for the youngest of children has not decreased over the past decade, despite improvements for older children. As health care professionals responsible for the overall health of children, pediatricians frequently confront morbidity associated with dental caries. Because the youngest children visit the pediatrician more often than they visit the dentist, it is important that pediatricians be knowledgeable about the disease process of dental caries, prevention of the disease, and interventions available to the pediatrician and the family to maintain and restore health.

Caregivers who refuse preventive care for their children: the relationship between immunization and topical fluoride refusal

OBJECTIVES

The aim of this study was to examine caregivers' refusal of preventive medical and dental care for children.

METHODS

Prevalence rates of topical fluoride refusal based on dental records and caregiver self-reports were estimated for children treated in 3 dental clinics in Washington State. A 60-item survey was administered to 1024 caregivers to evaluate the association between immunization and topical fluoride refusal. Modified Poisson regression models were used to estimate prevalence rate ratios (PRRs).

RESULTS

The prevalence of topical fluoride refusal was 4.9% according to dental records and 12.7% according to caregiver self-reports. The rate of immunization refusal was 27.4%. In the regression models, immunization refusal was significantly associated with topical fluoride refusal (dental record PRR = 1.61; 95% confidence interval [CI] = 1.32, 1.96; P < .001; caregiver self-report PRR = 6.20; 95% CI = 3.21, 11.98; P < .001). Caregivers younger than 35 years were significantly more likely than older caregivers to refuse both immunizations and topical fluoride (P < .05).

CONCLUSIONS

Caregiver refusal of immunizations is associated with topical fluoride refusal. Future research should identify the behavioral and social factors related to caregiver refusal of preventive care with the goal of developing multidisciplinary strategies to help caregivers make optimal preventive care decisions for children.

Prevention of dental caries in children from birth through age 5 years: US Preventive Services Task Force recommendation statement

DESCRIPTION

Update of the 2004 US Preventive Services Task Force (USPSTF) recommendation on prevention of dental caries in preschool-aged children.

METHODS

The USPSTF reviewed the evidence on prevention of dental caries by primary care clinicians in children 5 years and younger, focusing on screening for caries, assessment of risk for future caries, and the effectiveness of various interventions that have possible benefits in preventing caries.

POPULATION

This recommendation applies to children age 5 years and younger.

RECOMMENDATION

The USPSTF recommends that primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride. (B recommendation) The USPSTF recommends that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of routine screening examinations for dental caries performed by primary care clinicians in children from birth to age 5 years. (I Statement).

Tooth brushing frequency and use of fluoride lozenges in children from 1.5 to 5 years of age: a longitudinal study

OBJECTIVES

The purpose of the analyses was to study development, stability and changes in oral health behaviour - tooth brushing frequency, use of fluoride lozenges and fluoridated toothpaste in children from 1.5 to 5 years of age - and to study associations between oral health behaviour and family characteristics.

METHODS

This study was based on data from the Norwegian Mother and Child Cohort Study conducted by the Norwegian Institute of Public Health and data from the Public Dental Services. A total of 771 children were followed from 1.5 to 5 years of age. Questionnaires regarding oral health behaviour in children were completed by the parents three times during preschool age.

RESULTS

More than half of the children (52%) had their teeth brushed twice daily at 1.5 years of age, increasing to 61% at 3 years and 76% at 5 years of age. At 1.5 years of age, 37% of the children used fluoride lozenges daily, increasing to 74% at 3 years and 75% at 5 years of age. The majority of the children who had started brushing twice daily and used fluoride lozenges daily at 1.5 years of age continued these behaviours until the age of 5 years. At 1.5 years of age, children who brushed twice daily were more likely to use fluoride lozenges daily than children who brushed less frequently (P = 0.03). Multiple logistic regression showed that the probability of a child having its teeth brushed twice daily continuously during preschool age was higher when both parents were of western origin [odds ratios (OR) 4.0, confidence intervals (CI) 1.3-11.9] than when one or both parents were of non-western origin. Children with one older sibling brushed more frequently (OR 1.4, CI 1.0-1.9) and used fluoride lozenges more often (OR 1.6, CI 1.1-2.2) during preschool age than children without older siblings.

CONCLUSIONS

Oral health behaviour established in early life was stable during preschool age. The results indicate that tooth brushing frequency and use of fluoride lozenges were not in accordance with the present recommendations based on the scientific literature. The teeth of Norwegian preschoolers were brushed less frequently than recommended, and more children than recommended were using fluoride lozenges.

Impact of 24-month fluoride tablet program on children with disabilities in a non-fluoridated country

The aim of this study was to evaluate the caries preventive effects of a school-based fluoride tablet program in children with disabilities. Two hundred and seventeen children with disabilities were divided into two groups: the intervention group (IG) ingested 1.0mg fluoride tablet daily while the control group (CG) ingested a placebo. The initial oral examinations were conducted prior to fluoride intake and 24-month follow-up examinations were conducted to evaluate the effectiveness of fluoride tablet ingestion. The results from this study demonstrated significant reductions in the DMFT index (the sum of decayed, missing, and filled permanent teeth), 0.63, as well as the DMFS index (the sum of decayed, missing, and filled surfaces of the permanent dentition), 1.25, when compared with the CG. A statistically significant reduction in the DMFT index and DMFS index (30.42% and 36.84%, respectively) suggested an anti-cariogenic benefit to fluoride tablet administration. Greater caries reduction occurred on mesio-distal and bucco-lingual surfaces (53.27% and 52.57%, respectively). Fluoride tablets should be considered as a caries preventive strategy in school-based caries prevention programs for children with disabilities in fluoride deficient areas.

Early childhood caries: risk-based disease prevention and management

Early childhood caries (ECC), common in preschoolers, can lead to pain and infection if left untreated. Yet, ECC is largely preventable, and if it is identified early and the responsible risk factors are addressed, its progression can be halted or slowed. This article reviews the rationale for a first dental visit by age 1 year, caries risk assessment, and risk-based prevention and management of ECC and discusses strategies for providers to implement these contemporary evidence-based concepts into clinical practice.

Position of the Academy of Nutrition and Dietetics: the impact of fluoride on health

It is the position of the Academy of Nutrition and Dietetics to support optimal systemic and topical fluoride as an important public health measure to promote oral health and overall health throughout life. Fluoride is an important element in the mineralization of bone and teeth. The proper use of topical and systemic fluoride has resulted in major reductions in dental caries and its associated disability. Dental caries remains the most prevalent chronic disease in children and affects all age groups of the population. The Centers for Disease Control and Prevention has named fluoridation of water as one of the 10 most important public health measures of the 21st century. Currently, >72% of the US population that is served by community water systems benefits from water fluoridation. However, only 27 states provide fluoridated water to more than three quarters of the state's residents on public water systems. Fluoride also plays a role in bone health. However, at this time, use of high doses of fluoride for osteoporosis prevention is considered experimental only. Dietetics practitioners should routinely monitor and promote the use of fluorides for all age groups.

Limited evidence for preventing childhood caries using fluoride supplements

DATA SOURCES

The Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, WHOLIS/PAHO/MEDCARIB/LILACS/BBO and Current Controlled Trials databases. Selected authors were contacted and the reference lists of articles searched.

STUDY SELECTION

Randomised or quasi-randomised controlled trials with a minimum of two years' follow up comparing fluoride supplements (tablets, drops, lozenges) with no fluoride supplement or with other preventive measures such as topical fluorides in children less than 16 years of age at the start were included.

DATA EXTRACTION AND SYNTHESIS

Eligibility, risk of bias assessment and data abstraction were conducted by two authors independently and in duplicate. Disagreements were resolved by consensus and by consulting a third author. The prevented fraction (PF), defined as the mean caries increment in controls minus mean caries increment in the treated group divided by mean caries increment in controls was used to evaluate efficacy. Random-effects meta-analysis was used where the data could be pooled. Heterogeneity was assessed and adverse effects recorded when reported.

RESULTS

Eleven studies (involving 7196 children) were included. In permanent teeth, comparing fluoride supplements with no fluoride supplement, (three studies), supplement use was associated with a 24% (95% confidence interval (CI) 16 to 33%) reduction in decayed, missing and filled surfaces (DMFS). The effect of fluoride supplements was unclear on primary teeth. In one study, no caries-inhibiting effect was observed on deciduous teeth while in another study, the use of fluoride supplements was associated with a substantial reduction in caries increment.When fluoride supplements were compared with topical fluorides or with other preventive measures, there was no differential effect on permanent or deciduous teeth. The review found limited information on the adverse effects associated with the use of fluoride supplements.

CONCLUSIONS

This review suggests that the use of fluoride supplements is associated with a reduction in caries increment when compared with no fluoride supplement in permanent teeth. The effect of fluoride supplements was unclear on deciduous teeth. When compared with the administration of topical fluorides, no differential effect was observed. We rated 10 trials as being at unclear risk of bias and one at high risk of bias, and therefore the trials provide weak evidence about the efficacy of fluoride supplements.

Urinary fluoride concentration in children with disabilities following long-term fluoride tablet ingestion

Urine is the most commonly utilized biomarker for fluoride excretion in public health and epidemiological studies. Approximately 30-50% of fluoride is excreted from urine in children. Urinary fluoride excretion reflects the total fluoride intake from multiple sources. After administering fluoride tablets to children with disabilities, urinary fluctuation patterns should be investigated. The purpose of this study was to monitor the short and long term fluctuating patterns of urinary fluoride concentration after fluoride tablets were ingested by children with disabilities. Children with disabilities aged 6-12 years old were selected randomly and were divided into three groups: Group A, 1.0mg fluoride tablet, Group B, 0.5mg fluoride tablet, and Group C, control group. The urine samples were collected in the morning (MU) and 2h after fluoride tablets were ingested (AU). Urine was collected on the day prior to fluoride intake (baseline), the first, the third, the fifth and the eighth day of fluoride ingestion for a short term, and once every 6 months for a total of 18 months for long-term observation. The AU sample showed statistically significantly higher concentrations of urine fluoride than those of the MU samples, and no statistically significant difference was noticed in the MU samples among the three groups. Group A showed the highest urinary fluoride concentration (UFC) among the three groups. UFC increased as ingested fluoride tablet dosage increased, and it returned to the baseline level on the following day and persisted throughout the study period.

Use of dietary fluoride supplements by children living in Berlin, Germany, may have a dose-response preventive effect against dental caries, regardless of their use of fluoridated salt

PURPOSE/QUESTION

To assess benefits (caries prevention) and risks (dental fluorosis) of using dietary fluoride supplements (referred as “fluoride tablets” in the article) among children consuming fluoridated salt in a district of Berlin, Germany.

SOURCE OF FUNDING

Information not available. The authors acknowledged the cooperation of the Public Dental Services of the Steglitz-Zehlendorf district in Berlin

TYPE OF STUDY/DESIGN

Retrospective cohort study

LEVEL OF EVIDENCE

Level 2: Limited-quality, patient-oriented evidence

STRENGTH OF RECOMMENDATION GRADE

Not applicable