BACKGROUND: Topically-applied fluoride varnishes have been used extensively as an operator-applied caries-preventive intervention for over three decades. This review updates the first Cochrane review of fluoride varnishes for preventing dental caries in children and adolescents, which was first published in 2002. OBJECTIVES: To determine the effectiveness and safety of fluoride varnishes in preventing dental caries in children and adolescents, and to examine factors potentially modifying their effect. SEARCH METHODS: We searched the Cochrane Oral Health Group's Trials Register (to 13 May 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 4), MEDLINE via OVID (1946 to 13 May 2013), EMBASE via OVID (1980 to 13 May 2013), CINAHL via EBSCO (1980 to 13 May 2013), LILACS and BBO via the BIREME Virtual Health Library (1980 to 13 May 2013), ProQuest Dissertations and Theses (1861 to 13 May 2013), and Web of Science Conference Proceedings (1945 to 13 May 2013). A search for ongoing trials was undertaken on ClinicalTrials.gov on 13 May 2013. There were no restrictions on language or date of publication in the search of the electronic databases. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials with blind outcome assessment used or indicated, comparing topically-applied fluoride varnish with placebo or no treatment in children up to 16 years during at least one year. The main outcome was caries increment measured by the change in decayed, missing and filled tooth surfaces in both permanent (D(M)FS) and primary (d(e/m)fs) teeth. DATA COLLECTION AND ANALYSIS: At least two review authors assessed all search results, extracted data and undertook risk of bias independently. Study authors were contacted for additional information. The primary measure of effect was the prevented fraction, 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. The caries increments nearest to three years were used from each included study. Random-effects meta-analyses were performed where data could be pooled. Potential sources of heterogeneity were examined in random-effects meta-regression analyses. Adverse effects information was collected from the included trials. MAIN RESULTS: Twenty-two trials with 12,455 participants randomised (9595 used in analyses) were included. For the 13 that contributed data for the permanent tooth surfaces meta-analysis, the pooled D(M)FS prevented fraction estimate comparing fluoride varnish with placebo or no treatment was 43% (95% confidence interval (CI) 30% to 57%; P < 0.0001). There was substantial heterogeneity, confirmed statistically (P < 0.0001; I(2) = 75%), however this body of evidence was assessed as of moderate quality. The pooled d(e/m)fs prevented fraction estimate was 37% (95% CI 24% to 51%; P < 0.0001) for the 10 trials that contributed data for the primary tooth surfaces meta-analysis, also with some heterogeneity (P = 0.009; I(2) = 59%). Once again this body of evidence was assessed as of moderate quality. No significant association between estimates of D(M)FS or d(e/m)fs prevented fractions and the pre-specified factors of baseline caries severity, background exposure to fluorides, application features such as prior prophylaxis, concentration of fluoride, frequency of application were found. There was also no significant association between estimates of D(M)FS or d(e/m)fs prevented fractions and the post hoc factors: whether a placebo or no treatment control was used, length of follow-up, or whether individual or cluster randomisation was used, in the meta-regression models. A funnel plot of the trials in the main meta-analyses indicated no clear relationship between prevented fraction and study precision. In both methods, power is limited when few trials are included. There was little information concerning possible adverse effects or acceptability of treatment. AUTHORS' CONCLUSIONS: The conclusions of this updated review remain the same as those when it was first published. The review suggests a substantial caries-inhibiting effect of fluoride varnish in both permanent and primary teeth, however the quality of the evidence was assessed as moderate, as it included mainly high risk of bias studies, with considerable heterogeneity.

/pdf/fluoride-varnishes-for-preventing-dental-caries-in-children-3tv0b9jl4u.pdf

Fluoride varnishes for preventing dental caries in children and adolescents.

A systematic literature review from 1966 to 2000 revealed 2,730 English-language publications on the role of bacteria in human primary dental caries in vivo. The most pertinent 313 papers were analyzed in evidence tables accessible online (http://www.nidcr.nih.gov). The search targeted all bacterial types implicated previously in caries and asked two questions. First, what is the association of specific bacteria with tooth decay and can causation be attributed to any of those bacteria? Retrieved studies were categorized as randomized-blinded-interventional, longitudinal, case-control, and cross-sectional and were weighted in descending order in terms of significance. Although many studies, due to ethical requirements, had confounding variables, they still indicate strongly: 1) the central role of the mutans streptococci in initiation of caries of smooth surfaces and fissures of crowns of teeth and suggests their potent role in induction of root surface caries; and 2) that lactobacilli are implicated as important contributory bacteria in tooth decay, but their role in induction of lesions is not well supported. Second, what is the source of infection by cariogenic bacteria? Molecular/genetic studies of implicated bacteria isolated from humans, randomized-blinded-interventional, and longitudinal studies indicate that mutans streptococci are spread vertically among humans, mostly from mothers to their children. Implications of these conclusions are briefly discussed. The most significant problems of literature interpretation include the benefits/shortcomings of salivary and plaque monitoring of the flora, the role of sugar(s) in decay as it influences the flora, and modeling strategies to predict lesion score increments as distinct from determination of the etiological role of specific bacteria. Future directions for microbiological clinical caries research are suggested, and the use of the term "caries" to describe the disease, not its lesions, is urged.

The microbiology of primary dental caries in humans.

Background Topical fluoride therapy (TFT) in the form of varnish, gel, mouthrinse or toothpaste has been used extensively as a caries-preventive intervention for over three decades. Objectives To determine the effectiveness and safety of fluoride varnishes, gels, mouthrinses, and toothpastes in the prevention of dental caries in children and to examine factors potentially modifying their effect. Search strategy We searched the Cochrane Oral Health Group's Trials Register (May 2000), 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 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 There were 144 studies included. For the 133 that contributed data for meta-analysis (involving 65,169 children) the D(M)FS pooled prevented fraction estimate was 26% (95% CI, 24% to 29%; p Reviewer's conclusions The benefits of topical fluorides have been firmly established on a sizeable body of evidence from randomized controlled trials. While the formal examination of sources of heterogeneity between studies has been important in the overall conclusions reached, these should be interpreted with caution. We were unable to reach definite conclusions about any adverse effects that might result from the use of topical fluorides, because data reported in the trials are scarce.

/pdf/topical-fluoride-toothpastes-mouthrinses-gels-or-varnishes-3nj92a08qp.pdf

Topical fluoride (toothpastes, mouthrinses, gels or varnishes) for preventing dental caries in children and adolescents

A systematic review of the English-language literature was conducted to address three related questions concerning the diagnosis and management of dental caries: a) the performance (sensitivity, specificity) of currently available diagnostic methods for carious lesions, b) the efficacy of approaches to the management of noncavitated or initial carious lesions, and c) the efficacy of preventive methods among individuals who have experienced or are expected to experience elevated incidence of carious lesions. From 1,328 caries diagnostic and 1,435 caries management reports originally identified, thirty-nine diagnostic studies and twenty-seven management studies were included in the final evidence tables. Point estimates or reasonable range estimates for the diagnostic validity of methods for the diagnosis of carious lesions could not be established from the literature reviewed. There are insufficient numbers of reports of diagnostic performance involving primary teeth, anterior teeth, and root surfaces. For posterior occlusal and proximal surfaces, quality issues and the variation among studies precludes establishing such estimates. The apparent differences in sensitivity among methods are generally smaller than the variation reported within methods. The literature on the management of noncavitated carious lesions consisted of five studies describing seven experimental interventions. Because these interventions varied extensively in terms of management methods tested as well as other study characteristics, no conclusions about the efficacy of these methods were possible. The literature on the management of individuals at elevated risk of carious lesions consisted of twenty-two studies describing twenty-nine experimental interventions. The strength of the evidence for the efficacy of fluoride varnish for prevention of dental caries in high-risk subjects was fair, and the evidence for all other methods was incomplete. Because the evidence for efficacy for some methods, including chlorhexidine, sucrose-free gum, and combined chlorhexidine-fluoride methods, is suggestive but not conclusive, these interventions represent fruitful areas for further research.

Systematic Reviews of Selected Dental Caries Diagnostic and Management Methods

Background
A panel of experts convened by the American Dental Association (ADA) Council on Scientific Affairs presents evidence-based clinical recommendations regarding professionally applied and prescription-strength, home-use topical fluoride agents for caries prevention. These recommendations are an update of the 2006 ADA recommendations regarding professionally applied topical fluoride and were developed by using a new process that includes conducting a systematic review of primary studies.

/pdf/topical-fluoride-for-caries-prevention-2hy03g5m1m.pdf

Topical fluoride for caries prevention

– The caries preventive effect of topical application of fluoride varnish (Duraphat), ferric-aluminum-fluoride solution (FeAlF) and chlorhexidine gel was compared in a 2-yr clinical study. Children with more than 106 mutans streptococci per ml saliva were selected and a total of 189 13-yr-old children participated in the study. The children in the fluoride groups were treated every third month with either Duraphat or FeAlF-solution. In the chlorhexidine group children with more than 2.5 × 105 mutans streptococci per ml of saliva were treated every third month. The mean number of new decayed and filled tooth surfaces was 3.06 in the chlorhexidine group, 5.88 in the Duraphat group, 5.33 in the FeAlF group, and 6.34 in the control group. Thus supervised antimicrobial treatment can significantly reduce the incidence of dental (caries) in children with high numbers of mutans streptococci.

Effect of different carriers preventive measures in children highly infected with mutans streptococci.

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Effect of different carriers preventive measures in children highly infected with mutans streptococci.