Fluoride toothpastes of different concentrations for preventing dental caries in children and adolescents

 

Abstract

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.

 

摘要

背景

不同濃度含氟牙膏對於孩童和青少年預防蛀牙的效果

蛀牙是一種牙齒硬組織的疾病,主要造成原因為牙菌斑中致病的細菌和碳水化合物(主要是糖)的長時間不平衡交互作用所造成的.而利用含氟牙膏是最簡單去預防蛀牙的方式.

目標

研究不同濃度的含氟牙膏對於孩童或是青少年在預防蛀牙的效果,並且檢驗蛀牙的程度和刷牙的方式.

搜尋策略

搜尋是利用Cochrane Oral Health Group's Trials Register, CENTRAL, MEDLINE和several other databases.文章的參考文獻也會搜尋.最近的搜尋是在2009年的6月8日.

選擇標準

利用隨機控制試驗(Randomised controlled trials)或是聚集性隨機控制試驗(Randomised controlled trials)比較含氟牙膏和安慰劑或是不同濃度的含氟牙膏對於16歲以下的小朋友預防蛀牙的能力,所觀察的時間最少為一年.最初結果是利用在恆牙或乳牙上窩洞(decayed),缺牙(missing)或是填補牙齒的表面數目(filled tooth surfaces)來表示.

資料收集與分析

包含的研究是由兩位回顧者所搜集和評估,當有爭議時是經由向第三方討論和決定.最初影響測量為預防效果 (prevented fraction),蛀牙在對照組中比實驗組所增加的情況並且有適當的數據和經過數據的分析.而潛在異質性(Potential sources of heterogeneity)利用隨機數據分析檢驗是否正確.

主要結論

75篇文章被收集,其中的71篇包括79個互聯數據分析.66個研究中(74個試驗)利用D(M)FS在混和齒列或是恆牙齒列做數據分析, 可以發現比安慰劑來說高濃度含氟牙膏有23%(95%CrI(credible interval)為19% −27%)預防蛀牙的效果,而和濃度為1000/1055/1100/1200PPM的牙膏比較起來,使用2400/2500/2800PPM的牙膏有提高36%(95%CrI為27% −44%)預防蛀牙的效果.但是使用440/500/550PPM含氟牙膏和安慰劑比較在預防蛀牙的效果統計上的沒有差別.在預防蛀牙的效果上雖然當提高含氟濃度會有較好結果,但是不是都有統計上的顯著.含氟牙膏預防能力會因為原本資料D(M)FS增加或是刷牙的方式而有提升但是也沒有達到統計上的顯著.6個評估乳牙使用含氟牙膏的的結果顯示在含氟牙膏結果測量上是有歧異的.治療的結果或是不希望的影響只有在少數的文章中有被評估.治療的結果在不同文章的所觀察到是不一樣,而像是不希望影響如軟組織的傷害或是牙齒的染色的較少的.

作者結論

這篇回顧文章主要是要找到在小朋友及青少年使用含氟牙膏預防蛀牙是否有效,但是只有當含氟量多於1000ppm以上預防蛀牙的效果比不使用含氟牙膏才有統計上的顯著.當比較含氟牙膏濃度差別在預防蛀牙效果時,可以發現含氟量越高預防蛀牙的效果越好.當對於小於六歲的小朋友使用含氟牙膏時,要除了要考慮含氟量也要注意是否有造成氟中毒的危險.

翻譯人

本摘要由臺灣大學附設醫院杜元佑翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

比較小朋友或是青少年使用不同濃度的含氟牙膏預防蛀牙的效果:許多小朋友曾經因為嚴重的蛀牙而拔除其牙齒,或者雖然那顆牙齒沒有拔除但也因為治療而讓小朋友和照顧者需要請假來接受治療.其他回顧文章顯示使用含氟牙膏比使用沒有含氟牙膏預防蛀牙效果平均提高24%.而這篇回顧文章比較不同濃度含氟牙膏的效果.這其中包括了79個試驗和73000小朋友.當使用較高含氟量的牙膏可以有較好預防蛀牙的效果.而小朋友使用含氟牙膏的濃度至少要1000ppm以上才能有效預防蛀牙,而這結果支持現在國際間建議使用含氟牙膏的量.雖然所有所收集的試驗中沒有包含對於小朋友有氟中毒或是氟斑齒的研究.但是我們知道當小小朋友使用含氟牙膏時我們不希望會有氟中毒的情況.一個已發行的實證醫學回顧文章有討論到小小朋友氟中毒的問題.當有氟中毒的可能時可以和你的牙醫師討論,牙醫師可能會建議使用含氟量低於1000ppm的含氟牙膏.