Jennifer Hill DDS, PhD; Shabnam Sabounchei DDS
The ample scientific evidence that topical fluoride effectively reduces caries increment in children demonstrates its therapeutic importance in a caries prevention program.
A qualitative summary of fluoride reviews in the Cochrane Database of Systematic Reviews shows that fluoride toothpastes, rinses, gels and varnishes effectively prevent caries.
In children and adolescents, how effective are topical fluoride therapies in preventing caries according to the available Cochrane systematic reviews?
The authors searched the Cochrane Database of Systematic Reviews (CDSR), Issue 4, 2008 of The Cochrane Library for relevant systematic reviews using the terms “fluoride” and “caries”. The author scanned all records by title, and selected all reviews that assessed the effectiveness of any F-based intervention for caries. She did not consider reports of ongoing Cochrane reviews. Factors influencing effectiveness were assessed; together with effectiveness when used in combination, as well as their safety (and acceptability). A qualitative summary of the evidence was also presented.
Eleven complete Cochrane systematic reviews were identified. Seven reviews evaluated the effectiveness of four topical fluoride treatments (toothpastes, gels, varnishes and mouthrinses) in preventing caries. Four reviews assessed other fluoride modalities (slow-release devices, milk), specific comparison/site (fluoride varnishes versus sealants in occlusal surfaces), and particular population and caries outcomes (fluorides for white spot lesions in orthodontic patients). Topical fluoride treatments such as varnishes, gels and rinses have similar effectiveness in preventing caries. Additional caries reduction can be expected when topical fluoride is combined with fluoride toothpaste. However, the evidence is insufficient to support the effectiveness of slow-release fluoride devices and of fluoridated milk. Fissure sealants appear more effective than fluoride varnish for preventing occlusal caries, but the size of the difference is unclear.
The benefits of topical fluorides delivered in toothpastes, rinses, gels and varnishes in both the permanent and the primary dentitions are firmly established based on the large amount of evidence gathered from randomized controlled trials. However there is insufficient evidence for the effectiveness of slow release fluoride devices, milk fluoridation, relative effectiveness of sealants in comparison with fluoride varnishes, and of different modes of delivering fluoride to orthodontic patients.
Source of Funding:
Importance and Context:
Dental caries is the major cause of tooth morbidity and mortality. Topical fluorides are beneficial in reducing caries increment, based on a high level of evidence. Cochrane reviews have been shown to be of higher methodological quality than other systematic reviews. In this review, the author assessed and summarized their main methodological features and findings to facilitate their subsequent interpretation and use for developing practice recommendations.
Strengths and Weaknesses of the Systematic Review:
The author considered only complete systematic reviews from the Cochrane Database of Systematic Reviews. She provided a list of the included systematic reviews. One of the advantages of presenting together the reviews with similar (Cochrane) methodology is that sensible comparisons between different topical F treatments can be made, and results are not interpreted in isolation. However the fact that the author of this overview produced seven of the 11 reviews suggests potential bias.
Strengths and Weaknesses of the Evidence:
As of this critical summary, the Cochrane reviews of topical fluorides involve more than 65,000 children and adolescents in over 130 controlled trials. The author classified their main findings into six subcategories. She strengthened her conclusions by reviewing placebo-controlled trials. In no-treatment control topical F trials, caries reductions are overestimated; also, those types of trials that are not double-blind are likely to be of lower methodological quality. Apart from the indirect evidence of the trials, more robust investigations on direct evidence from head-to-head comparisons are necessary. Generally, the randomized evidence was lacking to support the benefit of fluoride in slow-release F devices, F milk, F varnishes versus fissure sealants, and F for white spot lesions in orthodontic patients.
Implications for Dental Practice:
Topical fluoride therapies should be the first choice in any caries preventive program. The greater acceptability of toothpaste supports its increased regular use for improving effectiveness. Furthermore, the daily use of fluoride toothpaste has a significant caries-preventive effect in children, an effect which is boosted by supervised tooth brushing, increased frequency to twice-daily brushing and toothpastes containing 1,500 ppm fluoride.(1)
1. S Twetman. Caries prevention with fluoride toothpaste in children: an update. Eur Arch Paediatr Dent. 2009 Sep;10(3):162-67.