Valeria CC Marinho1,*, Julian PT Higgins2, Stuart Logan3, Aubrey Sheiham4

Editorial Group: Cochrane Oral Health Group

 

Published Online: 21 JUL 2003

Assessed as up-to-date: 18 MAY 2003

DOI: 10.1002/14651858.CD002284

Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

The Cochrane Library

 

Background

Fluoride mouthrinses have been used extensively as a caries-preventive intervention in school-based programmes and individually at home.

 

Objectives

To determine the effectiveness and safety of fluoride mouthrinses in the prevention of dental caries in children and to examine factors potentially modifying their effect.

 

Search methods

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

 

Selection criteria

 

Randomised or quasi-randomised controlled trials with blind outcome assessment, comparing fluoride mouthrinse with placebo or no treatment 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 treatment 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. Potential sources of heterogeneity were examined in random-effects metaregression analyses.

 

Main results

Thirty-six studies were included. For the 34 that contributed data for meta-analysis (involving 14,600 children) the D(M)FS pooled PF was 26% (95% confidence interval (CI), 23% to 30%; P < 0.0001). Heterogeneity was not substantial, but confirmed statistically (P = 0.008). No significant association between estimates of D(M)FS prevented fractions and baseline caries severity, background exposure to fluorides, rinsing frequency and fluoride concentration was found in metaregression analyses. A funnel plot of the 34 studies indicated no relationship between prevented fraction and study precision. There is little information concerning possible adverse effects or acceptability of treatment in the included trials.

 

Authors' conclusions

 

This review suggests that the supervised regular use of fluoride mouthrinse at two main strengths and rinsing frequencies is associated with a clear reduction in caries increment in children. In populations with caries increment of 0.25 D(M)FS per year, 16 children will need to use a fluoride mouthrinse (rather than a non-fluoride rinse) to avoid one D(M)FS; in populations with a caries increment of 2.14 D(M)FS per year, 2 children will need to rinse to avoid one D(M)FS. There is a need for complete reporting of side effects and acceptability data in fluoride mouthrinse trials.

 

 

Plain language summary

Fluoride mouthrinses for preventing dental caries in children and adolescents

 

Regular supervised use of fluoride mouthrinses by children would reduce their tooth decay, even if they drink fluoridated water and use fluoridated toothpaste. 

Fluoride is a mineral that prevents tooth decay (dental caries). Since widespread use of fluoride toothpastes and water fluoridation, the value of additional fluoride has been questioned. Fluoride mouthrinse is a concentrated solution that needs to be used regularly to have an effect. The review of trials found that regular use of fluoride mouthrinse reduces tooth decay in children, regardless of other fluoride sources. One in two children with high levels of tooth decay (and one in 16 with the lowest levels) would have less decay. However, more research is needed on adverse effects and acceptability of mouthrinses.

 

 

 

 

 

 

 

 

Tanya Walsh1,*, Helen V Worthington2, Anne-Marie Glenny2, Priscilla Appelbe1, Valeria CC Marinho3, Xin Shi4

Editorial Group: Cochrane Oral Health Group

Published Online: 20 JAN 2010

Assessed as up-to-date: 25 AUG 2009

DOI: 10.1002/14651858.CD007868.pub2

Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

The Cochrane Library

 

Background

 

Caries (dental decay) is a disease of the hard tissues of the teeth caused by an imbalance, over time, in the interactions between cariogenic bacteria in dental plaque and fermentable carbohydrates (mainly sugars). The use of fluoride toothpaste is the primary intervention for the prevention of caries.

 

Objectives

 

To determine the relative effectiveness of fluoride toothpastes of different concentrations in preventing dental caries in children and adolescents, and to examine the potentially modifying effects of baseline caries level and supervised toothbrushing.

 

Search methods

A search was undertaken on Cochrane Oral Health Group's Trials Register, CENTRAL, MEDLINE and several other databases. Reference lists of articles were also searched. 

Date of the most recent searches: 8 June 2009.

 

Selection criteria

Randomised controlled trials and cluster-randomised controlled trials comparing fluoride toothpaste with placebo or fluoride toothpaste of a different concentration in children up to 16 years of age with a follow-up period of at least 1 year. The primary outcome was caries increment in the permanent or deciduous dentition as measured by the change in decayed, (missing), filled tooth surfaces (D(M)FS/d(m)fs) from baseline.

 

Data collection and analysis

Inclusion of studies, data extraction and quality assessment were undertaken independently and in duplicate by two members of the review team. Disagreements were resolved by discussion and consensus or by a third party. The primary effect measure was the prevented fraction (PF), the caries increment of the control group minus the caries increment of the treatment group, expressed as a proportion of the caries increment in the control group. Where it was appropriate to pool data, network meta-analysis, network meta-regression or meta-analysis models were used. Potential sources of heterogeneity were specified a priori and examined through random-effects meta-regression analysis where appropriate.

 

Main results

75 studies were included, of which 71 studies comprising 79 trials contributed data to the network meta-analysis, network meta-regression or meta-analysis.

 

For the 66 studies (74 trials) that contributed to the network meta-analysis of D(M)FS in the mixed or permanent dentition, the caries preventive effect of fluoride toothpaste increased significantly with higher fluoride concentrations (D(M)FS PF compared to placebo was 23% (95% credible interval (CrI) 19% to 27%) for 1000/1055/1100/1250 parts per million (ppm) concentrations rising to 36% (95% CrI 27% to 44%) for toothpastes with a concentration of 2400/2500/2800 ppm), but concentrations of 440/500/550 ppm and below showed no statistically significant effect when compared to placebo. There is some evidence of a dose response relationship in that the PF increased as the fluoride concentration increased from the baseline although this was not always statistically significant. The effect of fluoride toothpaste also increased with baseline level of D(M)FS and supervised brushing, though this did not reach statistical significance. Six studies assessed the effects of fluoride concentrations on the deciduous dentition with equivocal results dependent upon the fluoride concentrations compared and the outcome measure. Compliance with treatment regimen and unwanted effects was assessed in only a minority of studies. When reported, no differential compliance was observed and unwanted effects such as soft tissue damage and tooth staining were minimal.

 

Authors' conclusions

 

This review confirms the benefits of using fluoride toothpaste in preventing caries in children and adolescents when compared to placebo, but only significantly for fluoride concentrations of 1000 ppm and above. The relative caries preventive effects of fluoride toothpastes of different concentrations increase with higher fluoride concentration. The decision of what fluoride levels to use for children under 6 years should be balanced with the risk of fluorosis.

 

 

Plain language summary

Comparison between different concentrations of fluoride toothpaste for preventing tooth decay in children and adolescents

 

Many children experience painful tooth decay which can lead to the tooth/teeth being extracted. Even if teeth are not extracted the tooth decay may be distressing, be expensive to treat and may involve children and their carers having time off school and work.

 

Another Cochrane review showed that fluoride toothpastes do reduce dental decay, by about 24% on average, when compared with a non-fluoride toothpaste. This review compares toothpastes with different amounts of fluoride.

 

This review includes 79 trials on 73,000 children. As expected the use of toothpaste containing more fluoride is generally associated with less decay. Toothpastes containing at least 1000 parts per million (ppm) fluoride are effective at preventing tooth decay in children, which supports the current international standard level recommended.

 

Although none of the trials included in the review looked at fluorosis or mottling of the children's teeth, fluorosis may be an unwanted result of using fluoride toothpaste in young children and a Cochrane review on this topic has also been published. The possible risk of fluorosis should be discussed with your dentist who may recommend using a toothpaste containing less than 1000 ppm fluoride.

 

 

 

 

 

 

03/feb/2010 | News Europe

by Lisa Townshend, DT UK

 

LONDON, UK: Children’s toothpaste that contains low concentrations of fluoride fails to effectively combat tooth decay. For optimal prevention of cavities in children over age six, toothpastes should contain at least 1,000 parts per million of fluoride, according to a study carried out by the University of Manchester School of Dentistry. Toothpaste containing fluoride concentrations of less than this is as ineffective as toothpaste with no fluoride all.

 

The study, published in the latest issue of the Cochrane Library, a publication of the Cochrane Collaboration, examined results from 79 controlled clinical studies on 73,000 children and found

that the benefits of fluoride are reduced for low fluoride toothpastes.

 

“Toothpastes with lower fluoride levels, in the 440 to 550 range, give results that are no better than the results seen with toothpaste that does not contain fluoride,” said co-authors Prof.

Helen Worthington and Dr Anne-Marie Glenny.

 

The study also found that brushing children’s teeth with fluoride toothpaste before the age of 12 months could lead to an increased risk of developing mild fluorosis. Children’s toothpastes currently range from 100 parts per million to 1,400 parts per million.

 

“From a public health point of view, the risk of tooth decay and its consequences, such as pain and extractions, is greater than the small risk of fluorosis. Children would have to swallow a lot of toothpaste over a long period of time to get the severe brown mottling on the teeth, as opposed to the more typical mild white patches,” Dr Glenny said.

 

She added that for children considered to be at a high risk of tooth decay by their dentist, the benefit to oral health is likely to outweigh the risk of fluorosis. In such cases, careful brushing of children’s teeth with a small amount of toothpaste containing higher levels of fluoride would be beneficial.

 

“If in any doubt, we would advise parents to speak to their family dentist,” Dr Glenny said.

 

 

 

 

 

 

 

May CM Wong1,*, Anne-Marie Glenny2, Boyd WK Tsang1, Edward CM Lo1, Helen V Worthington2, Valeria CC Marinho3

Editorial Group: Cochrane Oral Health Group

 

Published Online: 20 JAN 2010

 

Assessed as up-to-date: 27 AUG 2009

 

DOI: 10.1002/14651858.CD007693.pub2

 

Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

 

The Cochrane Library

 

 

Background

For many years, topical use of fluorides has gained greater popularity than systemic use of fluorides. A possible adverse effect associated with the use of topical fluoride is the development of dental fluorosis due to the ingestion of excessive fluoride by young children with developing teeth.

 

Objectives

To describe the relationship between the use of topical fluorides in young children and the risk of developing dental fluorosis.

 

Search methods

Electronic search of the Cochrane Oral Health Group Trials Register, CENTRAL, MEDLINE, EMBASE, BIOSIS, Dissertation Abstracts and LILACS/BBO. Reference lists from relevant articles were searched. Date of the most recent searches: 9th March 09.

 

Selection criteria

 

Randomised controlled trials (RCTs), quasi-RCTs, cohort studies, case-control studies and cross-sectional surveys, in which fluoride toothpastes, mouthrinses, gels, foams, paint-on solutions, and varnishes were compared to an alternative fluoride treatment, placebo or no intervention group. Children under the age of 6 years at the time topical fluorides were used.

 

Data collection and analysis

Data from all included studies were extracted by two review authors. Risk ratios for controlled, prospective studies and odds ratios for case-control studies or cross-sectional surveys were extracted or calculated. Where both adjusted and unadjusted risk ratios or odds ratios were presented, the adjusted value was included in the meta-analysis.

 

Main results

25 studies were included: 2 RCTs, 1 cohort study, 6 case-control studies and 16 cross-sectional surveys. Only one RCT was judged to be at low risk of bias. The other RCT and all observational studies were judged to be at moderate to high risk of bias. Studies were included in four intervention/exposure comparisons. A statistically significant reduction in fluorosis was found if brushing of a child's teeth with fluoride toothpaste commenced after the age of 12 months odds ratio 0.70 (random-effects: 95% confidence interval 0.57 to 0.88) (data from observational studies). Inconsistent statistically significant associations were found between starting using fluoride toothpaste/toothbrushing before or after the age of 24 months and fluorosis (data from observational studies). From the RCTs, use of higher level of fluoride was associated with an increased risk of fluorosis. No significant association between the frequency of toothbrushing or the amount of fluoride toothpaste used and fluorosis was found.

 

Authors' conclusions

There should be a balanced consideration between the benefits of topical fluorides in caries prevention and the risk of the development of fluorosis. Most of the available evidence focuses on mild fluorosis. There is weak unreliable evidence that starting the use of fluoride toothpaste in children under 12 months of age may be associated with an increased risk of fluorosis. The evidence for its use between the age of 12 and 24 months is equivocal. If the risk of fluorosis is of concern, the fluoride level of toothpaste for young children (under 6 years of age) is recommended to be lower than 1000 parts per million (ppm).

 

More evidence with low risk of bias is needed. Future trials assessing the effectiveness of different types of topical fluorides (including toothpastes, gels, varnishes and mouthrinses) or different concentrations or both should ensure that they include an adequate follow-up period in order to collect data on potential fluorosis. As it is unethical to propose RCTs to assess fluorosis itself, it is acknowledged that further observational studies will be undertaken in this area. However, attention needs to be given to the choice of study design, bearing in mind that prospective, controlled studies will be less susceptible to bias than retrospective and/or uncontrolled studies.