Topical fluoride as a cause of dental fluorosis in children.

BACKGROUND: This is an update of a review first published in 2010. Use of topical fluoride has become more common over time. Excessive fluoride consumption from topical fluorides in young children could potentially lead to dental fluorosis in permanent teeth. OBJECTIVES: To describe the relationship between the use of topical fluorides in young children and the risk of developing dental fluorosis in permanent teeth. SEARCH METHODS: We carried out electronic searches of the Cochrane Oral Health Trials Register, CENTRAL, MEDLINE, Embase, three other databases, and two trials registers. We searched the reference lists of relevant articles. The latest search date was 28 July 2022. SELECTION CRITERIA: We included randomized controlled trials (RCTs), quasi-RCTs, cohort studies, case-control studies, and cross-sectional surveys comparing fluoride toothpaste, mouth rinses, gels, foams, paint-on solutions, and varnishes to a different fluoride therapy, placebo, or no intervention. Upon the introduction of topical fluorides, the target population was children under six years of age. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane and used GRADE to assess the certainty of the evidence. The primary outcome measure was the percentage prevalence of fluorosis in the permanent teeth. Two authors extracted data from all included studies. In cases where both adjusted and unadjusted risk ratios or odds ratios were reported, we used the adjusted value in the meta-analysis. MAIN RESULTS: We included 43 studies: three RCTs, four cohort studies, 10 case-control studies, and 26 cross-sectional surveys. We judged all three RCTs, one cohort study, one case-control study, and six cross-sectional studies to have some concerns for risk of bias. We judged all other observational studies to be at high risk of bias. We grouped the studies into five comparisons. Comparison 1. Age at which children started toothbrushing with fluoride toothpaste Two cohort studies (260 children) provided very uncertain evidence regarding the association between children starting to use fluoride toothpaste for brushing at or before 12 months versus after 12 months and the development of fluorosis (risk ratio (RR) 0.98, 95% confidence interval (CI) 0.81 to 1.18; very low-certainty evidence). Similarly, evidence from one cohort study (3939 children) and two cross-sectional studies (1484 children) provided very uncertain evidence regarding the association between children starting to use fluoride toothpaste for brushing before or after the age of 24 months (RR 0.83, 95% CI 0.61 to 1.13; very low-certainty evidence) or before or after four years (odds ratio (OR) 1.60, 95% CI 0.77 to 3.35; very low-certainty evidence), respectively. Comparison 2. Frequency of toothbrushing with fluoride toothpaste Two case-control studies (258 children) provided very uncertain evidence regarding the association between children brushing less than twice per day versus twice or more per day and the development of fluorosis (OR 1.63, 95% CI 0.81 to 3.28; very low-certainty evidence). Two cross-sectional surveys (1693 children) demonstrated that brushing less than once per day versus once or more per day may be associated with a decrease in the development of fluorosis in children (OR 0.62, 95% CI 0.53 to 0.74; low-certainty evidence). Comparison 3. Amount of fluoride toothpaste used for toothbrushing Two case-control studies (258 children) provided very uncertain evidence regarding the association between children using less than half a brush of toothpaste, versus half or more of the brush, and the development of fluorosis (OR 0.77, 95% CI 0.41 to 1.46; very low-certainty evidence). The evidence from cross-sectional surveys was also very uncertain (OR 0.92, 95% CI 0.66 to 1.28; 3 studies, 2037 children; very low-certainty evidence). Comparison 4. Fluoride concentration in toothpaste There was evidence from two RCTs (1968 children) that lower fluoride concentration in the toothpaste used by children under six years of age likely reduces the risk of developing fluorosis: 550 parts per million (ppm) fluoride versus 1000 ppm (RR 0.75, 95% CI 0.57 to 0.99; moderate-certainty evidence); 440 ppm fluoride versus 1450 ppm (RR 0.72, 95% CI 0.58 to 0.89; moderate-certainty evidence). The age at which the toothbrushing commenced was 24 months and 12 months, respectively. Two case-control studies (258 children) provided very uncertain evidence regarding the association between fluoride concentrations under 1000 ppm, versus concentrations of 1000 ppm or above, and the development of fluorosis (OR 0.89, 95% CI 0.52 to 1.52; very low-certainty evidence). Comparison 5. Age at which topical fluoride varnish was applied There was evidence from one RCT (123 children) that there may be little to no difference between a fluoride varnish application before four years, versus no application, and the development of fluorosis (RR 0.77, 95% CI 0.45 to 1.31; low-certainty evidence). There was low-certainty evidence from two cross-sectional surveys (982 children) that the application of topical fluoride varnish before four years of age may be associated with the development of fluorosis in children (OR 2.18, 95% CI 1.46 to 3.25). AUTHORS' CONCLUSIONS: Most evidence identified mild fluorosis as a potential adverse outcome of using topical fluoride at an early age. There is low- to very low-certainty and inconclusive evidence on the risk of having fluorosis in permanent teeth for: when a child starts receiving topical fluoride varnish application; toothbrushing with fluoride toothpaste; the amount of toothpaste used by the child; and the frequency of toothbrushing. Moderate-certainty evidence from RCTs showed that children who brushed with 1000 ppm or more fluoride toothpaste from one to two years of age until five to six years of age probably had an increased chance of developing dental fluorosis in permanent teeth. It is unethical to propose new RCTs to assess the development of dental fluorosis. However, future RCTs focusing on dental caries prevention could record children's exposure to topical fluoride sources in early life and evaluate the dental fluorosis in their permanent teeth as a long-term outcome. In the absence of these studies and methods, further research in this area will come from observational studies. 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 uncontrolled studies.

Do chewing gums and sweets containing xylitol prevent caries in children?

DATA SOURCES: Three electronic databases (Pubmed, Embase and the Cochrane Library) were searched in December 2022, and again for additional literature on 3-5th January 2023. Reference lists of relevant systematic reviews were hand searched for other eligible studies for inclusion. STUDY SELECTION: Randomised controlled clinical trials and controlled clinical trials conducted on children (aged ≤ 18 years), conducted between 1974-2022 and available in English, were eligible for inclusion. Studies were excluded if caries was not an outcome, the control group was not sufficient, they were lab-based studies or studies where xylitol delivery was not a sweet or chewing gum and where the xylitol product contained a component such as fluoride which may influence the outcomes. DATA EXTRACTION AND SYNTHESIS: Four calibrated reviewers independently screened titles and abstracts, and disagreements were resolved via group discussion. Preventative effect was determined by comparing the mean caries increment in the control and intervention groups, producing a preventative fraction. A total of 617 titles were initially screened for relevance. After duplicate removal, 268 abstracts were screened and 16 full text articles reviewed, with one more study then excluded. 10 studies investigated xylitol-containing chewing gum, and six looked at xylitol candy (one did both). Eight included studies were randomised controlled trials. Data extraction was undertaken by two reviewers. RESULTS: 3466 participants were included in the 10 studies that investigated xylitol chewing gum, and all 10 studies reported a statistically significant preventive effect compared to a no chewing gum or placebo control. In 9 studies, the preventive fraction was clinically significant. The six studies investigating xylitol candies contained a total of 1023 participants, and only one study demonstrated a significant preventative effect. CONCLUSIONS: There is some evidence that incorporating xylitol chewing gum daily has a caries-reducing effect in those with a moderate-to-high baseline caries level. This effect was not present for xylitol sweets.

Immediate and sustained root caries prevention of fluoride varnish combined with toothpastes: findings of clinical relevance?

DESIGN: An in vitro study to determine the immediate and sustained effect of fluoride varnish and its combination with fluoride toothpastes in preventing the development of root caries. CASE SELECTION: Human root dentine samples (150) were randomly divided into five experimental protocols of 30 specimens each: 1) fluoride varnish (22,600 ppm fluoride and 1-5% CPP-ACP); 2) fluoride varnish followed by Paste One (1100 ppm sodium fluoride and CPP-ACP); 3) fluoride varnish followed by Paste Plus (900 ppm sodium fluoride and CPP-ACP); 4) fluoride varnish followed by Paste One and Paste Plus; and 5) no treatment (control). A layer of varnish was applied to specimens except the control group and was left in situ for 18 h. The varnish layer was removed, and the various toothpaste treatments were initiated. Half of the specimens in each group were assigned to a short-term incubation model in which they were immediately subjected to a 7-day cariogenic challenge consisting of a combination of human saliva and artificial saliva containing 2% sucrose. The other half of the specimens in each group were assigned to the long-term incubation model in which the experimental protocol was continued for 8 weeks before initiating the seven-day cariogenic challenge. The protocols were evaluated by assessing dentine porosity (rhodamine intensity), mineral density, biofilm biomass, and viability assays. DATA ANALYSIS: Confocal laser scanning microscopy was used to determine dentine porosity and Levene's test was used to verify the assumption of equality of variances and normal distribution of errors before two-way ANOVA and the Games-Howell test were carried out at a significance level of 0.05 for both incubation models. Microcomputed tomography was used to determine mineral density with statistical analysis involving Levene's test, two-way ANOVA and Tukey's test at a significance level of 0.05 for both incubation models. Biomass was evaluated using a biofilm biomass assay with analysis of optical density data using Levene's test, ANOVA and Scheffe's test at a significance level of 0.05. RESULTS: For both the short- and long-term incubation models, all the experimental regimes resulted in a statistically significant decrease in dentine porosity and an increase in mineral density when compared to the control group. Fluoride varnish followed by both pastes and fluoride varnish followed by Paste One resulted in a statistically significant decrease in dentine porosity for some depths in both models when compared to fluoride varnish alone. Changes in dentine porosity and mineral density were observed within groups over time. All the experimental regimes demonstrated anti-biofilm effects. Immediate and sustained anti-caries effects were observed for all preventive protocols, with the combination of fluoride varnish and Paste One resulting in superior additional anti-caries effects. CONCLUSIONS: The authors concluded that all protocols demonstrated immediate and sustained anti-caries effects against the development of root caries despite variations in effects over time. The combination of fluoride varnish and Paste One resulted in additional anti-caries effects that were consistently superior, with no additional effects being observed when Paste Plus was added in combination. The authors suggest that, within the study's limitations, topical fluoride varnish seems to have a protective effect on root surfaces for up to eight weeks and that fluoride varnish should be considered as an important adjunct strategy in the prevention of root caries in older adults.

Comparison of the effects of fluoride varnish containing silver nanoparticles and conventional fluoride varnish on the surface microhardness of tooth enamel.

BACKGROUND: Nano-silver fluoride (NSF) has been introduced to improve enamel lesions. The effective use of varnishes is important in the prevention of dental caries. OBJECTIVES: The study aimed to compare the effect of conventional sodium fluoride varnish with the same varnish containing 1% and 2% silver nanoparticles (AgNP) on the surface microhardness of enamel. MATERIAL AND METHODS: The baseline surface microhardness of 40 premolar teeth was measured using a Vickers microhardness tester. After immersing the samples in a demineralizing agent for 24 h, the microhardness was measured again. In group B, a layer of conventional fluoride varnish was applied to the tooth surfaces using a microbrush with soft bristles, following the manufacturer's instructions. Groups C and D were treated with 1% and 2% NSF varnishes, respectively, while group A received no varnish. Surface microhardness tests were conducted on all specimens, including those previously tested. RESULTS: The microhardness of the enamel surface increased significantly in all 3 test groups compared to the microhardness after demineralization (p < 0.05). CONCLUSIONS: Conventional fluoride varnish and fluoride varnishes containing 1% and 2% AgNP are equally effective in remineralizing initial caries.

Professionally applied fluorides for preventing and arresting dental caries in low- and middle-income countries: Systematic review.

OBJECTIVES: This systematic review aimed to review the safety and effectiveness of professionally applied fluorides for preventing and arresting dental caries in low- and middle-income countries (LMICs). METHODS: Randomized controlled trials conducted in LMICs, in which professionally applied fluorides were compared with placebo/no treatment/health education only or usual care with a minimum one-year follow-up period, were included. Any topically applied fluoride agents such as sodium fluoride (NaF), acidulated phosphate fluoride, silver diamine fluoride (SDF), and nano silver fluoride (NSF) were included. Five databases (PubMed, Embase, Scopus, Web of Science, and Cochrane Library) were searched in May 2022. Meta-analysis was conducted using a random effect model. RESULTS: This review included 33 studies for qualitative synthesis, encompassing 16,375 children aged between 1.5 and 14 years. Nevertheless, the meta-analysis focused on only 17 studies, involving 4067 children. Fourteen papers assessed potential adverse events, none of which was reported as major adverse events. SDF and NSF were identified as effective in arresting caries on primary teeth (p < 0.05) compared with a placebo or no treatment. Fluoride varnish and gel were identified as effective in reducing new caries development on primary teeth (p < 0.05) but not on permanent teeth (p > 0.05). The certainty of the generated evidence obtained is low. CONCLUSION: The review provides valuable insights into the use of professionally applied fluorides in LMICs and contributes to recommendations for their use. However, the limited rigorous evidence suggests the need for further research to strengthen these findings and draw more robust conclusions.

Using sequential applications of a novel silver diamine fluoride gel and sodium fluoride varnish to arrest severe early childhood caries lesions: A clinical trial with single group assignment.

BACKGROUND: Silver diamine fluoride (SDF) gel was developed to overcome the clinical limitations of liquids with children. The authors conducted a clinical trial to determine caries lesion arrest in primary teeth at 1-year follow-up when 38% SDF gel and 2.5% sodium fluoride varnish were applied sequentially at the same appointment. Parent satisfaction was assessed. METHODS: The study design was an open-label prospective, clinical trial with single group assignment. Participants were 237 children aged 3 through 4 years at enrollment and from 5 centros educativos iniciales (preschools). Eligible children had 1 or more d3 (cavitation into dentin) active caries lesions. Teeth with active caries lesions (cavitation confined to enamel [d2] or d3) were treated by applying 1 or 2 drops of viscous 38% SDF gel (Advantage Silver Dental Arrest Gel, Elevate Oral Care, LLC) dabbing the excess with cotton. Treated teeth were covered with 2.5% sodium fluoride varnish (Fluorimax, Elevate Oral Care, LLC) to mask the taste. Treatment was repeated at 5 months postexamination. The primary outcome was caries lesion (d2-d3) arrest at 1 year. RESULTS: Two hundred nineteen children were available at the 1-year follow-up. There was a median of 21 (interquartile range [IQR], 13-34) active carious surfaces (d2-d3) at baseline. Median arrested carious surfaces was 92.6% (IQR, 81.1%-100.0%; 95% CI, 86.8% to 95.2%). When parents were asked whether they were bothered by the color change of teeth, the median response on a 10-point scale in which 1 equaled not bothered at all and 10 equaled very bothered was 1.0 (IQR, 1.0-2.0). CONCLUSIONS: Two applications of 38% SDF gel and 2.5% sodium fluoride varnish arrested greater than 90% of carious surfaces at 1 year and with high levels of parental satisfaction. PRACTICAL IMPLICATIONS: Combined treatment was highly efficacious in a population with many caries lesions. This clinical trial was registered at ClinicalTrials.gov. The registration number is NCT05395065.

Salivary and urinary assessment of fluoride and silver ion concentrations after silver diamine fluoride application in children: a prospective cohort study.

PURPOSE: The purpose of the study was to determine the fluoride (F) and silver (Ag) ions levels in the saliva and urine of healthy children after silver diamine fluoride (SDF) application on dental carious lesions. METHODS: Sixty children (4-6 years with ≥ 3 caries lesions) were recruited from the outpatient department of Pediatric Dentistry. From each child, 3 ml unstimulated saliva samples were collected at baseline, one hour, and 24 h after SDF application. Similarly, 3 ml urine samples were collected prior to and after 24 h of SDF application. F and Ag ion concentrations were determined by fluoride ion-selective electrode (ISE) and inductively coupled plasma mass spectrometry (ICPMS), respectively. RESULTS: The mean ± standard deviation (SD) baseline, 1-h, and 24-h salivary F concentrations (ppm) were 0.07 ± 0.07, 0.93 ± 0.48, and 0.19 ± 0.19, respectively, while the mean baseline and 24-h urinary F concentrations (ppm) were 0.33 ± 0.20 ppm and 0.43 ± 0.25 ppm, respectively. The mean baseline, 1-h, and 24-h salivary Ag concentrations (ppb) were 4.22 ± 3.15, 4198 ± 350, and 56.93 ± 37, respectively. The mean baseline and 24-h urinary Ag concentrations (ppb) were 2.80 ± 2.93 ppb and 4.72 ± 4.0 ppb, respectively. There were statistically elevated F and Ag ion concentrations at 1 h and 24 h after SDF application as compared to the baseline. CONCLUSION: Salivary and urinary F and Ag ions concentrations elevated significantly at 24 h following SDF applications in children. A significant high recovery of these ions in urine indicates minimal systemic absorption, thus intermittent topical application of 38% SDF has a minimal risk of toxicity.

Screening, Referral, Behavioral Counseling, and Preventive Interventions for Oral Health in Children and Adolescents Aged 5 to 17 Years: A Systematic Review for the US Preventive Services Task Force.

Importance: Dental caries is common in children and adolescents aged 5 to 17 years and potentially amenable to primary care screening and prevention. Objective: To systematically review the evidence on primary care screening and prevention of dental caries in children and adolescents aged 5 to 17 years to inform the US Preventive Services Task Force. Data Sources: MEDLINE, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews (to October 3, 2022); surveillance through July 21, 2023. Study Selection: Diagnostic accuracy of primary care screening instruments and oral examination; randomized and nonrandomized trials of screening and preventive interventions and systematic reviews of such studies; cohort studies on primary care oral health screening and preventive intervention harms. Data Extraction and Synthesis: One investigator abstracted data; a second checked accuracy. Two investigators independently rated study quality. Random-effects meta-analysis was performed for fluoride supplements and xylitol; for other preventive interventions, pooled estimates were used from good-quality systematic reviews. Main Outcomes and Measures: Dental caries, morbidity, functional status, quality of life, harms; diagnostic test accuracy. Results: Three systematic reviews (total 20 684 participants) and 19 randomized clinical trials, 3 nonrandomized trials, and 1 observational study (total 15 026 participants) were included. No study compared screening vs no screening. When administered by dental professionals or in school settings, fluoride supplements compared with placebo or no intervention were associated with decreased change from baseline in the number of decayed, missing, or filled permanent teeth (DMFT index) or decayed or filled permanent teeth (DFT index) (mean difference, -0.73 [95% CI, -1.30 to -0.19]) at 1.5 to 3 years (6 trials; n = 1395). Fluoride gels were associated with a DMFT- or DFT-prevented fraction of 0.18 (95% CI, 0.09-0.27) at outcomes closest to 3 years (4 trials; n = 1525), fluoride varnish was associated with a DMFT- or DFT-prevented fraction of 0.44 (95% CI, 0.11-0.76) at 1 to 4.5 years (5 trials; n = 3902), and resin-based sealants were associated with decreased risk of carious first molars (odds ratio, 0.21 [95% CI, 0.16-0.28]) at 48 to 54 months (4 trials; n = 440). No trial evaluated primary care counseling or dental referral. Evidence on screening accuracy, silver diamine fluoride, xylitol, and harms was very limited, although serious harms were not reported. Conclusions and Relevance: Administration of fluoride supplements, fluoride gels, varnish, and sealants in dental or school settings improved caries outcomes. Research is needed on the effectiveness of oral health preventive interventions in primary care settings and to determine the benefits and harms of screening.

Effects of bovine milk osteopontin on in vitro enamel remineralization as a topical application prior to immersion in remineralizing solutions with/without fluoride.

The aim of the present study was to investigate the effects of bovine milk osteopontin (OPN) on enamel remineralization as a topical application prior to immersion in remineralizing solutions with/without fluoride. Bovine enamel blocks were demineralized then were divided into the following 3 groups: OPN (2.7 and 5.4 µM) solutions and deionized water (control). Each group was divided into 2 groups (remineralizing solution with or without 1 ppm of fluoride (F)). The specimens were analyzed by micro-CT and scanning electron microscope (SEM). The percentage of remineralization was higher in remineralization solution with than without F (p<0.05). The present results suggest that bovine milk OPN inhibits remineralization in solution without F, but 5.4 µM bovine milk OPN does not inhibit remineralization of the demineralized body using solution containing F by interrupting mineral deposition on the enamel surface.

Screening and Interventions to Prevent Dental Caries in Children Younger Than 5 Years: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.

Importance: A 2014 review for the US Preventive Services Task Force (USPSTF) found that oral fluoride supplementation and topical fluoride use were associated with reduced caries incidence in children younger than 5 years. Objective: To update the 2014 review on dental caries screening and preventive interventions to inform the USPSTF. Data Sources: Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews (to September 2020); surveillance through July 23, 2021. Study Selection: Randomized clinical trials (RCTs) on screening, preventive interventions, referral to dental care; cohort studies on screening and referral; studies on diagnostic accuracy of primary care oral examination or risk assessment; and a systematic review on risk of fluorosis included in prior USPSTF reviews. Data Extraction and Synthesis: One investigator abstracted data; a second checked accuracy. Two investigators independently rated study quality. Results: Thirty-two studies (19 trials, 9 observational studies, and 4 nonrandomized clinical intervention studies [total 106 694 participants] and 1 systematic review [19 studies]) were included. No study evaluated effects of primary care screening on clinical outcomes. One study (n = 258) found primary care pediatrician examination associated with a sensitivity of 0.76 (95% CI, 0.55 to 0.91) and specificity of 0.95 (95% CI, 0.92 to 0.98) for identifying a child with cavities, and 1 study found a risk assessment tool associated with sensitivity of 0.53 and specificity of 0.77 (n = 697, CIs not reported) for a child with future caries. No new trials of dietary fluoride supplementation were identified. For prevention, topical fluoride compared with placebo or no topical fluoride was associated with decreased caries burden (13 trials, n = 5733; mean caries increment [difference in decayed, missing, and filled teeth or surfaces], -0.94 [95% CI, -1.74 to -0.34]) and likelihood of incident caries (12 trials, n = 8177; RR, 0.80 [95% CI, 0.66 to 0.95]; absolute risk difference, -7%) in higher-risk populations or settings, with no increased fluorosis risk. Evidence on other preventive interventions was limited (education, xylitol) or unavailable (silver diamine fluoride), and no study directly evaluated primary care dentistry referral vs no referral. Conclusions and Relevance: There was no direct evidence on benefits and harms of primary care oral health screening or referral to dentist. Dietary fluoride supplementation and fluoride varnish were associated with improved caries outcomes in higher-risk children and settings.

Screening and Interventions to Prevent Dental Caries in Children Younger Than 5 Years: US Preventive Services Task Force Recommendation Statement.

Importance: Dental caries is the most common chronic disease in children in the US. According to the 2011-2016 National Health and Nutrition Examination Survey, approximately 23% of children aged 2 to 5 years had dental caries in their primary teeth. Prevalence is higher in Mexican American children (33%) and non-Hispanic Black children (28%) than in non-Hispanic White children (18%). Dental caries in early childhood is associated with pain, loss of teeth, impaired growth, decreased weight gain, negative effects on quality of life, poor school performance, and future dental caries. Objective: To update its 2014 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a systematic review on screening and interventions to prevent dental caries in children younger than 5 years. Population: Asymptomatic children younger than 5 years. Evidence Assessment: The USPSTF concludes with moderate certainty that there is a moderate net benefit of preventing future dental caries with oral fluoride supplementation at recommended doses in children 6 months or older whose water supply is deficient in fluoride. The USPSTF concludes with moderate certainty that there is a moderate net benefit of preventing future dental caries with fluoride varnish application in all children younger than 5 years. The USPSTF concludes that the evidence is insufficient on performing routine oral screening examinations for dental caries by primary care clinicians in children younger than 5 years and that the balance of benefits and harms of screening cannot be determined. Recommendation: The USPSTF recommends that primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride. (B recommendation) The USPSTF recommends that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of routine screening examinations for dental caries performed by primary care clinicians in children younger than 5 years. (I statement).

Antimicrobial and cytotoxic capacity of pyroligneous extracts films of Eucalyptus grandis and chitosan for oral applications.

Chitosan films containing distilled pyroligneous extracts of Eucalyptus grandis (DPEC), characterized and developed by Brazilian Agricultural Research Corporation-Embrapa Temperate Agriculture (EMBRAPA-CPACT), were evaluated for antimicrobial activity against Candida albicans, Streptococcus mutans, and Lactobacillus acidophilus by direct contact test. Further, their capacity for the prevention of teeth enamel demineralization and cytotoxicity in vitro were also determined. The natural polymers were tested at different concentrations (1500-7500 µg mL-1) and the formulation of an experimental fluoride varnish with antimicrobial activity was evaluated by direct contact test, whereas cytotoxicity was analyzed through the colorimetric MTT assay. Preliminary data showed no statistically significant differences in cytotoxicity to NIH/3T3 cell line when DPEC is compared to the control group. On the other hand, the antimicrobial capacity and demineralization effects were found between the test groups at the different concentrations tested. Chitosan films containing distilled pyroligneous extracts of E. grandis may be an effective control strategy to prevent biofilm formation related to dental caries when applied as a protective varnish. They may inhibit the colonization of oral microorganisms and possibly control dental caries through a decrease in pH and impairment of enamel demineralization.

Fabrication of oral nanovesicle in-situ gel based on Epigallocatechin gallate phospholipid complex: Application in dental anti-caries.

The conventional anti-caries agents exhibit many shortcomings such as poor stability, low efficacy or short residence time in the oral environment, it is urgent to develop efficacy treatments to prevent dental caries. As the most active polyphenols from tea, Epigallocatechin gallate (EGCG) shows remarkable anti-cariogenic bioactivity. However, the poor stability and low bioavailability of EGCG limit its potential application. This study aimed to fabricate nanovesicles in-situ gel based on EGCG phospholipid complex in order to increase its stability and efficacy. The formation of EGCG phospholipid complex was characterized by Fourier transform infrared spectroscopy (FTIR) and differential scanning calorimetry (DSC). The ethanol injection method was used to prepare the EGCG-loaded nanovesicles, an optimal ratio of Poloxamer407 (P407) and Poloxamer188 (P188) as in-situ gel matrix was selected to fabricate oral nanovesicles in-situ gel. EGCG-loaded nanovesicle in-situ gel based on the phospholipid complex had uniform spherical shape without any agglomeration. The discrete nanoparticle with a size (131.44 ± 4.24 nm) and a negative zeta potential value at -30.7 ± 0.5 mV possessed good physical stability and high entrapment efficiency (83.66 ± 3.2%). The formulation exhibited a strong antibacterial activity on S. mutans, which could reduce acid production and tooth surface adhesion. In addition, EGCG formulation could inhibit the formation of glucan and biofilm from S. mutans by suppressing the activity of glycosyltransferase enzymes (GTF). In conclusion, the EGCG-loaded nanovesicle in-situ gel holds great promise as an efficient anti-cariogenic formulation for topical oral delivery.

Effectiveness of a toothpaste and a serum containing calcium silicate on protecting the enamel after interproximal reduction against demineralization.

To evaluate the effectiveness of a calcium silicate/phosphate fluoridated tooth paste and a serum compared with a toothpaste containing hydroxyapatite on protecting the enamel after interproximal reduction against demineralization. 3 sets of eleven incisors were created. The teeth underwent interproximal enamel reduction (IER) of 0.5 mm. Each set was allocated to one of three groups: (1) Brushing without toothpaste (control group); (2) Vitis toothpaste + Remin Pro; (3) Regenerate toothpaste + Regenerate Serum. The agents were applied three times a day and specimens subjected to demineralization cycles for 30 days. The weight percentages of calcium (Ca) and phosphorous (P) were quantified by X-ray microfluorescence spectroscopy. Surface microhardness measurements and electron scanning microscopy (SEM) observations were made. Ca data and the Ca/P ratio were significantly higher in Group 3 than the other groups (p < 0.017), while P was significantly lower in Group 3 (p < 0.017). No significant differences were found between Groups 1 and 2 (p > 0.017). Group 3 showed significantly higher microhardness values (p < 0.05) than Group 1. No significant differences were found for other comparisons between groups (p < 0.05). SEM images showed less demineralization in Group 3. The application of a calcium silicate/phosphate fluoridated tooth paste (Regenerate advance) and a dual serum (Regenerate advance enamel serum) protect the enamel with interproximal reduction against demineralization. Therefore, this treatment could be used to prevent the dissolution of hydroxyapatite after IER.

Silver diamine fluoride compared to atraumatic restorative technique for the treatment of caries in primary and mixed first phase dentition. / Fluoruro diamino de plata comparado con técnica de restauración atraumática para el tratamiento de caries cavitadas en dentición primaria y mixta primera fase.

INTRODUCTION: Cavitated carious lesions in primary and mixed dentition require prompt treatment to control caries progression. Silver diamine fluoride has emerged as an alternative to the atraumatic restorative technique due to its easy application. However, there is still uncertainty regarding its effectiveness and safety. METHODS: We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a metanalysis and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS: We identified ten systematic reviews, including two studies overall, which are randomized trials. We concluded that silver diamine fluoride compared to the atraumatic restorative technique may increase the arrest of caries in primary and mixed first phase dentition, however, the certainty of the evidence has been assessed as low. On the other hand, treatment with silver diamine fluoride compared to the atraumatic restorative technique (ART) probably increases the risk of adverse events.

INTRODUCCIÓN: Las lesiones de caries cavitadas en dentición primaria y mixta requieren un tratamiento oportuno, para evitar así la progresión de la caries. El fluoruro diamino de plata ha surgido como una alternativa a la técnica de restauración atraumática debido a su fácil aplicación. Sin embargo, aún existe incertidumbre en relación a su efectividad y seguridad. MÉTODOS: Realizamos una búsqueda en Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante el cribado de múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, analizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES: Identificamos diez revisiones sistemáticas que en conjunto incluyeron dos estudios primarios, ambos ensayos aleatorizados. Concluimos que el fluoruro diamino de plata en comparación a la técnica de restauración atraumática podría aumentar el arresto de caries en dentición primaria y mixta primera fase, pero la certeza de la evidencia ha sido evaluada como baja. Por otra parte, el tratamiento con fluoruro diamino de plata comparado con la técnica de restauración atraumática (ART) probablemente aumenta el riesgo de eventos adversos.

Impact of self-assembling peptides in remineralisation of artificial early enamel lesions adjacent to orthodontic brackets.

Enamel demineralisation can occur as a side effect during orthodontic treatment with fixed appliances. This study aimed to evaluate the efficacy of the self-assembling peptide P11-4 for remineralisation combined with fluorides, compared to application of fluoride varnish alone. De- and remineralisation was assessed by Quantitative light-induced fluorescence (QLF). Orthodontic brackets were bonded on 108 human enamel samples and white spot lesions were created. The samples were allocated randomly into three groups: Group I received no treatment, group II had a single application of fluoride varnish (22,600 ppm), and group III was treated with P11-4 following a single application of fluoride varnish. Quantitative light-induced fluorescence (QLF) measurements were performed at baseline, after demineralisation and after storage in remineralisation solution for 7 and 30 days. Non-parametric tests (Kruskal-Wallis test and Friedman test) were used for further analysis. After demineralisation, all samples showed a median ΔF -9.38% ± 2.79. After 30 days median ΔF values were as followed: group I = -9.04% ± 2.51, group II = -7.89 ± 2.07, group III = -6.08% ± 2.79). The median ΔF values differed significantly between all groups at all investigation times (p < 0.00001). Application of P11-4 with fluoride varnish was superior to the use of fluorides alone for remineralisation of enamel adjacent to brackets.

Prevalence and incidence of dental caries associated with the effect of tooth brushing and fluoride varnishing in schoolchildren at Galapagos Islands, Ecuador: Protocol of the EESO-Gal study / Prevalencia e incidencia de caries dental y efecto del cepillado dental acompañado de barniz de flúor en escolares de Islas Galápagos, Ecuador: protocolo del estudio EESO-Gal.

Introduction: Dental caries is the most prevalent oral disease in Ecuador. In our country, there are no studies that have included the population of the Galapagos Islands. Fluoride application to incipient lesions of dental caries has shown to be effective in avoiding the use of invasive restorative procedures. Objectives: The objective of the EESO-Gal study is to determine the prevalence and incidence of dental caries and to evaluate the effect of supervised dental brushing, accompanied by periodic applications of fluoride varnish on incipient precarious lesions of schoolchildren in the Galapagos Islands. This article presents the protocol of the EESO-Gal study. Methods: A cohort is planned with Galapagos Islands schoolchildren to determine the prevalence and incidence of dental caries, with assessments every six months, during twenty-four months. Results: We expect to determine the prevalence and incidence of caries every six months, for twenty-four months, in schoolchildren between three and ten years of age, and obtain data to show the state of the caries conditions in Galapagos schoolchildren, with the inclusion of daily brushing at school, supervised by the teacher, and with the application of fluoride varnish every six months. Conclusions: The prevalence of dental caries and incidence after the program will demonstrate the importance of implementing oral health prevention and promotion actions to create hygiene and health habits from an early age.

Introducción: La caries dental es la enfermedad bucal más prevalente en Ecuador. En nuestro país no existen estudios que hayan considerado a la población de las Islas Galápagos. La aplicación de flúor sobre lesiones incipientes de caries dental ha demostrado efectividad para evitar ejecutar procedimientos invasivos restauradores. Objetivos: El objetivo del Estudio de Salud Oral Galápagos, EESO-Gal, es determinar la prevalencia e incidencia de caries dental y evaluar el efecto de la acción del cepillado dental supervisado, acompañado de aplicaciones periódicas de flúor en barniz sobre lesiones cariosas incipientes en escolares de las Islas Galápagos. Con este informe se busca reportar el protocolo del Estudio de Salud Oral Galápagos. Métodos: Se plantea realizar una cohorte con los escolares de las Islas Galápagos para determinar la prevalencia e incidencia de caries con evaluaciones cada seis meses durante veinticuatro meses. Resultados: Se espera determinar la prevalencia e incidencia de caries cada seis meses durante veinticuatro meses en escolares de tres a diez años y obtener datos que permitan evidenciar el estado de las condiciones de caries en los escolares de Galápagos con la inclusión del cepillado diario en la escuela, supervisado por el docente, y con la aplicación semestral del barniz de flúor. Conclusiones: La prevalencia de caries dental e incidencia después de las acciones tomadas demostrará la importancia de aplicar acciones de prevención y promoción de la salud oral, para crear hábitos de higiene y salud desde edades tempranas.

Prevalencia e incidencia de caries dental y efecto del cepillado dental acompañado de barniz de flúor en escolares de Islas Galápagos, Ecuador: protocolo del estudio EESO-Gal / Prevalence and incidence of dental caries associated with the effect of tooth brushing and fluoride varnishing in schoolchildren at Galapagos Islands, Ecuador: Protocol of the EESO-Gal study

INTRODUCCIÓN: La caries dental es la enfermedad bucal más prevalente en Ecuador. En nuestro país no existen estudios que hayan considerado a la población de las Islas Galápagos. La aplicación de flúor sobre lesiones incipientes de caries dental ha demostrado efectividad para evitar ejecutar procedimientos invasivos restauradores. OBJETIVOS: El objetivo del Estudio de Salud Oral Galápagos, EESO-Gal, es determinar la prevalencia e incidencia de caries dental y evaluar el efecto de la acción del cepillado dental supervisado, acompañado de aplicaciones periódicas de flúor en barniz sobre lesiones cariosas incipientes en escolares de las Islas Galápagos. Con este informe se busca reportar el protocolo del Estudio de Salud Oral Galápagos. MÉTODOS: Se plantea realizar una cohorte con los escolares de las Islas Galápagos para determinar la prevalencia e incidencia de caries con evaluaciones cada seis meses durante veinticuatro meses. RESULTADOS: Se espera determinar la prevalencia e incidencia de caries cada seis meses durante veinticuatro meses en escolares de tres a diez años y obtener datos que permitan evidenciar el estado de las condiciones de caries en los escolares de Galápagos con la inclusión del cepillado diario en la escuela, supervisado por el docente, y con la aplicación semestral del barniz de flúor. CONCLUSIONES: La prevalencia de caries dental e incidencia después de las acciones tomadas demostrará la importancia de aplicar acciones de prevención y promoción de la salud oral, para crear hábitos de higiene y salud desde edades tempranas.

INTRODUCTION: Dental caries is the most prevalent oral disease in Ecuador. In our country, there are no studies that have included the population of the Galapagos Islands. Fluoride application to incipient lesions of dental caries has shown to be effective in avoiding the use of invasive restorative procedures. OBJECTIVES: The objective of the EESO-Gal study is to determine the prevalence and incidence of dental caries and to evaluate the effect of supervised dental brushing, accompanied by periodic applications of fluoride varnish on incipient precarious lesions of schoolchildren in the Galapagos Islands. This article presents the protocol of the EESO-Gal study. METHODS: A cohort is planned with Galapagos Islands schoolchildren to determine the prevalence and incidence of dental caries, with assessments every six months, during twenty-four months. RESULTS: We expect to determine the prevalence and incidence of caries every six months, for twenty-four months, in schoolchildren between three and ten years of age, and obtain data to show the state of the caries conditions in Galapagos schoolchildren, with the inclusion of daily brushing at school, supervised by the teacher, and with the application of fluoride varnish every six months. CONCLUSIONS: The prevalence of dental caries and incidence after the program will demonstrate the importance of implementing oral health prevention and promotion actions to create hygiene and health habits from an early age.

Modified toothpaste application using prepared toothpaste delivering technique increases interproximal fluoride toothpaste delivery.

OBJECTIVES: We devised a "prepared toothpaste delivering technique" (PTD technique), a modified the application of toothpaste method for using fluoride toothpaste more effectively. This study aimed to investigate the change in viscosity and fluoride intake into hydroxyapatite of a toothpaste, and deliverability of fluoride toothpaste to the interproximal site with the PTD technique using an interproximal model. METHODS: Eight toothpaste samples were prepared at the following concentrations: ×1.00, ×1.25, ×1.50, ×1.75, ×2.00, ×3.00, ×4.00, and ×5.00. Viscosity of the toothpaste was measured by a Type-B viscometer. Dissolution rate of toothpaste and fluoride uptake into the hydroxy apatite pellet were analyzed by a fluoride selective electrode. Application paste volume and delivery rate was measured using interproximal model and image analysis software during using a finger brush front (FBF), finger brush back (FBB), and toothbrush. RESULTS: As the dilution ratio increased, the viscosity of the toothpaste decreased sharply, F uptake decreased, and dissolution rate increased. F uptake was significantly reduced when the toothpaste was diluted more than 1.75 times. Therefore, in order to improve the effectiveness of the fluoride toothpaste, it is important to deliver the toothpaste to interproximal areas and pit clefts at low dilution. It was observed that PTD technique can be effectively implemented by the finger brush. CONCLUSIONS: The use of a FBF surface in the analysis of an acrylic interproximal model could aid in applying pressure while blocking the space of the groove and preventing outflow of the toothpaste. It was considered that the PTD technique would improve the effects of the fluoride toothpaste, especially in the interproximal site.