Clinical effects of preventive regimens for young people in their early and middle teens in relation to previous experience with dental prevention

Mechanical and chemical plaque control in the simultaneous management of gingivitis and caries: a systematic review

AIM

To report the evidence on the effect of mechanical and/or chemical plaque control in the simultaneous management of gingivitis and caries.

MATERIAL AND METHODS

A protocol was designed to identify randomized (RCTs) and controlled (CCTs) clinical trials, cohort studies and prospective case series (PCS), with at least 6 months of follow-up, reporting on plaque, gingivitis and caries. Relevant information was extracted from full papers, including quality and risk of bias. Meta-analyses were performed whenever possible.

RESULTS

After the screening of 1,373 titles, 15 RCTs, 10 CCTs and 2 PCS were included. Low to moderate evidence support that combined professional and self-performed mechanical plaque control significantly reduces standardized plaque index [n = 4; weighted mean difference (WMD) = 1.294; 95% CI (0.445; 2.144); p = 0.003] and gingivitis scores [n = 4; WMD = 1.728; 95% CI (0.631; 2.825); p = 0.002]. The addition of fluoride to mechanical plaque control is relevant for caries management [n = 5; WMD = 1.159; 95% CI (0.145; 2.172); p = 0.025] while chlorhexidine rinses are relevant for gingivitis.

CONCLUSION

Mechanical plaque control procedures are effective in reducing plaque and gingivitis. The addition of fluoride to mechanical plaque control is significant for caries management. Chlorhexidine rinse has a positive effect on gingivitis and inconclusive role in caries.

One topical fluoride (toothpastes, or mouthrinses, or gels, or varnishes) versus another for preventing dental caries in children and adolescents

BACKGROUND

Topical fluorides in the form of toothpaste, mouthrinse, varnish and gel are effective caries preventive measures. However, there is uncertainty about the relative value of these interventions.

OBJECTIVES

To compare the effectiveness of one form of topical fluoride intervention with another when used for the prevention of dental caries in children.

SEARCH STRATEGY

We searched the Cochrane Oral Health Group's Trials Register (May 2000), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2000), MEDLINE (1966 to January 2000), plus several other databases. We handsearched journals, reference lists of articles and contacted selected authors and manufacturers.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials with blind outcome assessment, comparing fluoride varnish, gel, mouthrinse, or toothpaste with each other in children up to 16 years during at least 1 year. The main outcome was caries increment measured by the change in decayed, missing and filled tooth surfaces (D(M)FS).

DATA COLLECTION AND ANALYSIS

Inclusion decisions, quality assessment and data extraction were duplicated in a random sample of one third of studies, and consensus achieved by discussion or a third party. Authors were contacted for missing data. The primary measure of effect was the prevented fraction (PF) that is the difference in mean caries increments between the 'experimental' and 'control' groups expressed as a percentage of the mean increment in the control group. Random effects meta-analyses were performed where data could be pooled.

MAIN RESULTS

There were 17 studies included, and 15 contributed data for the meta-analyses. Fluoride toothpaste was not significantly different from mouthrinse (pooled DMFS PF 0%; 95% CI, -18% to 19%; p = 0.94), or gel (pooled DMFS PF 0%; 95% CI, -21% to 21%; p = 1), or both gel and mouthrinse (pooled DMFS PF 1%; 95% CI, -13% to 14%; p = 0.94); heterogeneity was substantial. Results from the single trial comparing toothpaste with varnish (in deciduous teeth) were inconclusive (dfs PF 5%; CI not obtainable). The pooled results from the comparisons of fluoride varnish with mouthrinse was a non-significant difference favouring varnish (DMFS PF 10%; 95% CI, -12% to 32%; p = 0.40), but this result was not robust to sensitivity analysis performed, and heterogeneity was considerable. Results from the single trial comparing varnish with gel (14%, 95% CI, -12% to 40%; p = 0.30) and the single trial comparing gel with mouthrinse (-14% DMFS PF; 95% CI, -40% to 12%; p = 0.30) were inconclusive (favoured varnish and mouthrinse respectively).

REVIEWER'S CONCLUSIONS

Fluoride toothpastes in comparison to mouthrinses or gels appear to have a similar degree of effectiveness for the prevention of dental caries in children. There is no clear suggestion that fluoride varnish is more effective than mouthrinses and the evidence for the comparative effectiveness of fluoride varnishes and gels, and mouthrinses and gels is inconclusive. No conclusions about adverse effects could be reached, because no data were reported on in the trials. Acceptance is likely to be greater for fluoride toothpaste.

An evaluation of the use of professional (operator-applied) topical fluorides

Application of fluoride solutions, gels, varnishes, and prophylaxis pastes is reviewed as well as the sequential APF/SnF2 office-rinse method. The most widely-used technique is with 1.23% APF gel (12,300 ppm F) in trays. Clinical results from this method are similar to those achieved with an APF solution of the same fluoride concentration. A professional APF gel/tray application need not be preceded by a prophylaxis, should last four min, and should not be followed by a water rinse for 30 min. Fluoride varnishes are newer topical fluoride agents, but their relative efficacy, compared with other proven caries-inhibitory methods, remains to be fully determined. In general, fluoride prophylaxis pastes have not been shown to inhibit caries; however, their use is justified by the ability of some to replenish fluoride lost from the abrasive action of the paste on tooth enamel. The sequential office-rinse method has not been tested in randomized clinical trials, and its use cannot be recommended.