Efficacy of 1.23% APF gel applications on incipient carious lesions: a double-blind randomized clinical trial

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

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

How to cite this article

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

Is professionally applied topical fluoride effective in treating incipient caries? A systematic review

The present systematic review aimed to investigate the effectiveness of professionally applied topical fluoride as therapeutic agent for incipient carious lesions in permanent teeth. Randomised clinical trials (RCTs) comparing the effectiveness of professionally applied topical fluoride (varnish or gel) with that of placebo, no intervention, and toothbrushing (control group) in the treatment of incipient carious lesions in permanent dentition were included. An electronic search was performed in the PubMed, Web of Science, Scopus, Virtual Health Library, Embase, and Cochrane databases, in the grey literature, and in clinical trials registered until January 2021. Two reviewers independently screened titles and abstracts and assessed the risk of bias using the Cochrane tool. The certainty of evidence was classified using GRADE. A total of 2,223 articles were screened using titles/abstracts. After full-text reading of the 22 selected studies, nine RCTs were included. Five RCTs found that topical fluoride may be effective in reversing incipient carious lesions in permanent teeth. Overall, five studies were classified as having a low risk of bias and four as having some concerns. Only descriptive analysis was performed because of the heterogeneity of the data. Studies comparing fluoride varnish with usual home care oral hygiene have demonstrated topical fluoride does not appear to be more effective in improving the appearance of incipient carious lesions. Therefore, usual home care oral hygiene with fluoride toothpaste may be sufficient to treat incipient carious lesions in permanent dentition. Further studies with greater methodological rigor are, however, required to reduce bias, to allow a meta-analysis, and to draw well-founded conclusions (CRD42019120406).

Efficacy of fluoride gel in arresting active non-cavitated caries lesions: a randomized clinical trial

This study evaluated the efficacy of fluoride gel in arresting active non-cavitated caries lesions in permanent teeth. This randomized, triple-blind, placebo-controlled clinical trial randomized 100 schoolchildren aged 10.7 ± 2.2 years to test treatment (1.23% acidulated phosphate fluoride [APF] gel) or control treatment (placebo gel) for 4-6 applications at weekly intervals. Data collection included the visible plaque index, gingival bleeding index, visible plaque accumulation on the occlusal surfaces, eruption stage, and dental caries. The association between group and lesion arrestment was assessed using logistic regression, and estimates were adjusted for plaque accumulation over the lesion at baseline, surface type, and tooth type. Models were fitted using generalized estimating equations for accounting for the clustering of data (i.e., the same individual contributed > 1 lesion). Ninety-eight children completed the study (48 fluoride and 50 placebo). When all dental surfaces were analyzed, the likelihood of lesion arrestment was similar between both groups (p > 0.05). A secondary analysis including only the occlusal lesions in molars showed that for teeth under eruption, lesions receiving the 1.23% APF gel were about 3-fold more likely to become arrested than lesions receiving the placebo gel (OR = 2.85; 95%CI = 1.23-6.61; p = 0.01). No significant difference was detected for molars with complete eruption (p > 0.05). The benefit of fluoride gel for arresting non-cavitated caries lesions could not be identified by clinical assessment in this short-term trial. Notwithstanding, when the cariogenic challenge was greater (as on the occlusal surfaces of erupting molars), 1.23% APF gel treatment was an important tool for caries control.

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.

Efficacy of 1.23% acidulated phosphate fluoride gel on non-cavitated enamel lesions: a randomized clinical trial

A randomized controlled parallel clinical trial was conducted to evaluate the efficacy of the association of 1.23% topical professional acidulated phosphate fluoride (APF) gel with oral hygiene and dietary instructions on the arrest of active non-cavitated lesions in permanent, mixed, and temporary dentition in children between 3 and 12 years of age. Ninety-eight caries-active children were randomly divided into two groups: a fluoride gel group (n = 49) and a non-fluoridated gel group (n = 49). Each group received up to eight weekly applications of gel, weekly professional toothbrushing with oral hygiene instructions and dietary counselling. Caries lesions were assessed qualitatively through visual-tactile criteria performed in three stages: initial, intermediate, and final. Regression models were applied to identify risk indicators for caries control. Between-group comparison regarding the time taken to arrest the lesions was performed using Chi-squared and Fisher's exact tests. Seventeen children did not receive the allocated intervention, and one was lost to follow-up (n = 80). There was no difference between the control and placebo groups regarding the time to the arrest of the lesion (p >.05). The treatments showed similar results without significant statistical difference (p = 0.33; 95%CI: 0.32-1.48). No adverse effects were observed. It can be concluded that no additional effect of the association of 1.23% APF gel with oral hygiene using fluoride dentifrice and dietary instructions on the arrest of active non-cavitated lesions could be established. We can also confirm the importance of toothbrushing frequency and, consequently, the visible plaque reduction in the control of caries activity. RBR-37V5S3.

Evidence-based clinical practice guideline on nonrestorative treatments for carious lesions: A report from the American Dental Association

BACKGROUND

An expert panel convened by the American Dental Association Council on Scientific Affairs and the Center for Evidence-Based Dentistry conducted a systematic review and formulated evidence-based clinical recommendations for the arrest or reversal of noncavitated and cavitated dental caries using nonrestorative treatments in children and adults.

TYPES OF STUDIES REVIEWED

The authors conducted a systematic search of the literature in MEDLINE and Embase via Ovid, Cochrane CENTRAL, and Cochrane database of systematic reviews to identify randomized controlled trials reporting on nonrestorative treatments for noncavitated and cavitated carious lesions. The authors used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty in the evidence and move from the evidence to the decisions.

RESULTS

The expert panel formulated 11 clinical recommendations, each specific to lesion type, tooth surface, and dentition. Of the most effective interventions, the panel provided recommendations for the use of 38% silver diamine fluoride, sealants, 5% sodium fluoride varnish, 1.23% acidulated phosphate fluoride gel, and 5,000 parts per million fluoride (1.1% sodium fluoride) toothpaste or gel, among others. The panel also provided a recommendation against the use of 10% casein phosphopeptide-amorphous calcium phosphate.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Although the recommended interventions are often used for caries prevention, or in conjunction with restorative treatment options, these approaches have shown to be effective in arresting or reversing carious lesions. Clinicians are encouraged to prioritize use of these interventions based on effectiveness, safety, and feasibility.

Nonrestorative Treatments for Caries: Systematic Review and Network Meta-analysis

The goal of nonrestorative or non- and microinvasive caries treatment (fluoride- and nonfluoride-based interventions) is to manage the caries disease process at a lesion level and minimize the loss of sound tooth structure. The purpose of this systematic review and network meta-analysis was to summarize the available evidence on nonrestorative treatments for the outcomes of 1) arrest or reversal of noncavitated and cavitated carious lesions on primary and permanent teeth and 2) adverse events. We included parallel and split-mouth randomized controlled trials where patients were followed for any length of time. Studies were identified with MEDLINE and Embase via Ovid, Cochrane CENTRAL, and Cochrane Database of Systematic Reviews. Pairs of reviewers independently conducted the selection of studies, data extraction, risk-of-bias assessments, and assessment of the certainty in the evidence with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Data were synthesized with a random effects model and a frequentist approach. Forty-four trials (48 reports) were eligible, which included 7,378 participants and assessed the effect of 22 interventions in arresting or reversing noncavitated or cavitated carious lesions. Four network meta-analyses suggested that sealants + 5% sodium fluoride (NaF) varnish, resin infiltration + 5% NaF varnish, and 5,000-ppm F (1.1% NaF) toothpaste or gel were the most effective for arresting or reversing noncavitated occlusal, approximal, and noncavitated and cavitated root carious lesions on primary and/or permanent teeth, respectively (low- to moderate-certainty evidence). Study-level data indicated that 5% NaF varnish was the most effective for arresting or reversing noncavitated facial/lingual carious lesions (low certainty) and that 38% silver diamine fluoride solution applied biannually was the most effective for arresting advanced cavitated carious lesions on any coronal surface (moderate to high certainty). Preventing the onset of caries is the ultimate goal of a caries management plan. However, if the disease is present, there is a variety of effective interventions to treat carious lesions nonrestoratively.

The effects of three remineralizing agents on regression of white spot lesions in children: A two-week, single-blind, randomized clinical trial

BACKGROUND

This study investigated the effect of three remineralizing agents on improving white spot lesions (WSLs).

MATERIAL AND METHODS

This clinical trial included children who had at least one WSL on anterior teeth of upper or lower jaws. The participants were randomly assigned to 4 groups by treatment: 1) a cream containing casein phosphopeptide-amorphous calcium phosphate and fluoride (MI Paste Plus); 2) a cream containing hydroxyapatite and fluoride (Remin Pro); 3) a 2% sodium fluoride gel; and 4) usual home care (control). The treatment was performed for 3 times over 10 days using special trays for retaining remineralizing agents. The area and mineral content of WSLs were measured at baseline (T1) and 1 day after finishing treatment (T2). Blinding was applied for outcome assessment.

RESULTS

Eighty patients were assigned to MI Paste Plus, Remin Pro, NaF or control groups. The application of all remineralizing agents caused a significant decrease in area and a significant increase in mineral content of WSLs (p<0.05), whereas the control patients did not experience any significant alteration (p>0.05). At T2, the area of WSLs was significantly lower in three experimental groups compared to the control group (p=0.023), but between-group difference in mineral content of WSLs failed to achieve statistical significance (p=0.08).

CONCLUSIONS

The in-office application of either MI Paste Plus or Remin Pro was as effective as 2% NaF for reducing area and increasing mineral content of WSLs. MI Paste Plus and Remin Pro could be recommended as suitable alternatives to NaF for managing WSLs. Key words:White spot lesion, caries, casein phosphopeptide-amorphous calcium phosphate, hydroxyapatite, sodium fluoride, CPP-ACP, MPlus, Remin Pro, NaF.

Caries remineralisation and arresting effect in children by professionally applied fluoride treatment - a systematic review

BACKGROUND

As a low-cost and easily operated treatment, the use of professionally applied topical fluoride was approved for preventing dental caries and remineralising early enamel caries or white spot lesions. It is also used to arrest dentine caries. The aim of this study is to investigate the clinical efficacy of professional fluoride therapy in remineralising and arresting caries in children.

METHOD

A systematic search of publications from 1948 to 2014 was conducted using four databases: PubMed, Cochrane Library, ISI Web of Science and Embase. The key words used were (fluoride) AND (remineralisation OR remineralization OR arresting) AND (children caries OR early childhood caries). The title and abstract of initially identified publications were screened. Clinical trials about home-use fluorides, laboratory studies, case reports, reviews, non-English articles and irrelevant studies were excluded. The full texts of the remaining papers were retrieved. Manual screening was conducted on the bibliographies of the remaining papers to identify relevant articles.

RESULTS

A total of 2177 papers were found, and 17 randomised clinical trials were included in this review. Ten studies investigated the remineralising effect on early enamel caries using silicon tetrafluoride, fluoride gel, silver diamine fluoride or sodium fluoride. Seven studies reported an arresting effect on dentine caries using silver diamine fluoride or nano-silver fluoride. Meta-analysis was performed on four papers using 5 % sodium fluoride varnish to remineralise early enamel caries, and the overall percentage of remineralised enamel caries was 63.6 % (95 % CI: 36.0 % - 91.2 %; p < 0.001). Meta-analysis was also performed on five papers using 38 % silver diamine fluoride to arrest dentine caries and the overall proportion of arrested dentine caries was 65.9 % (95 % CI: 41.2 % - 90.7 %; p < 0.001).

CONCLUSION

Professionally applied 5 % sodium fluoride varnish can remineralise early enamel caries and 38 % silver diamine fluoride is effective in arresting dentine caries.