Water fluoridation for the prevention of dental caries.

BACKGROUND: Dental caries is a major public health problem in most industrialised countries, affecting 60% to 90% of school children. Community water fluoridation (CWF) is currently practised in about 25 countries; health authorities consider it to be a key strategy for preventing dental caries. CWF is of interest to health professionals, policymakers and the public. This is an update of a Cochrane review first published in 2015, focusing on contemporary evidence about the effects of CWF on dental caries. OBJECTIVES: To evaluate the effects of initiation or cessation of CWF programmes for the prevention of dental caries. To evaluate the association of water fluoridation (artificial or natural) with dental fluorosis. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase and four other databases up to 16 August 2023. We also searched two clinical trials registers and conducted backward citation searches. SELECTION CRITERIA: We included populations of all ages. For our first objective (effects of initiation or cessation of CWF programmes on dental caries), we included prospective controlled studies comparing populations receiving fluoridated water with those receiving non-fluoridated or naturally low-fluoridated water. To evaluate change in caries status, studies measured caries both within three years of a change in fluoridation status and at the end of study follow-up. For our second objective (association of water fluoridation with dental fluorosis), we included any study design, with concurrent control, comparing populations exposed to different water fluoride concentrations. In this update, we did not search for or include new evidence for this objective. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. For our first objective, we included the following outcomes as change from baseline: decayed, missing or filled teeth ('dmft' for primary and 'DMFT' for permanent teeth); decayed, missing or filled tooth surfaces ('dmfs' for primary and 'DMFS' for permanent teeth); proportion of caries-free participants for both primary and permanent dentition; adverse events. We stratified the results of the meta-analyses according to whether data were collected before or after the widespread use of fluoride toothpaste in 1975. For our second objective, we included dental fluorosis (of aesthetic concern, or any level of fluorosis), and any other adverse events reported by the included studies. MAIN RESULTS: We included 157 studies. All used non-randomised designs. Given the inherent risks of bias in these designs, particularly related to management of confounding factors and blinding of outcome assessors, we downgraded the certainty of all evidence for these risks. We downgraded some evidence for imprecision, inconsistency or both. Evidence from older studies may not be applicable to contemporary societies, and we downgraded older evidence for indirectness. Water fluoridation initiation (21 studies) Based on contemporary evidence (after 1975), the initiation of CWF may lead to a slightly greater change in dmft over time (mean difference (MD) 0.24, 95% confidence interval (CI) -0.03 to 0.52; P = 0.09; 2 studies, 2908 children; low-certainty evidence). This equates to a difference in dmft of approximately one-quarter of a tooth in favour of CWF; this effect estimate includes the possibility of benefit and no benefit. Contemporary evidence (after 1975) was also available for change in DMFT (4 studies, 2856 children) and change in DMFS (1 study, 343 children); we were very uncertain of these findings. CWF may lead to a slightly greater change over time in the proportion of caries-free children with primary dentition (MD -0.04, 95% CI -0.09 to 0.01; P = 0.12; 2 studies, 2908 children), and permanent dentition (MD -0.03, 95% CI -0.07 to 0.01; P = 0.14; 2 studies, 2348 children). These low-certainty findings (a 4 percentage point difference and 3 percentage point difference for primary and permanent dentition, respectively) favoured CWF. These effect estimates include the possibility of benefit and no benefit. No contemporary data were available for adverse effects. Because of very low-certainty evidence, we were unsure of the size of effects of CWF when using older evidence (from 1975 or earlier) on all outcomes: change in dmft (5 studies, 5709 children), change in DMFT (3 studies, 5623 children), change in proportion of caries-free children with primary dentition (5 studies, 6278 children) or permanent dentition (4 studies, 6219 children), or adverse effects (2 studies, 7800 children). Only one study, conducted after 1975, reported disparities according to socioeconomic status, with no evidence that deprivation influenced the relationship between water exposure and caries status. Water fluoridation cessation (1 study) Because of very low-certainty evidence, we could not determine if the cessation of CWF affected DMFS (1 study conducted after 1975; 2994 children). Data were not available for other review outcomes for this comparison. Association of water fluoridation with dental fluorosis (135 studies) The previous version of this review found low-certainty evidence that fluoridated water may be associated with dental fluorosis. With a fluoride level of 0.7 parts per million (ppm), approximately 12% of participants had fluorosis of aesthetic concern (95% CI 8% to 17%; 40 studies, 59,630 participants), and approximately 40% had fluorosis of any level (95% CI 35% to 44%; 90 studies, 180,530 participants). Because of very low-certainty evidence, we were unsure of other adverse effects (including skeletal fluorosis, bone fractures and skeletal maturity; 5 studies, incomplete participant numbers). AUTHORS' CONCLUSIONS: Contemporary studies indicate that initiation of CWF may lead to a slightly greater reduction in dmft and may lead to a slightly greater increase in the proportion of caries-free children, but with smaller effect sizes than pre-1975 studies. There is insufficient evidence to determine the effect of cessation of CWF on caries and whether water fluoridation results in a change in disparities in caries according to socioeconomic status. We found no eligible studies that report caries outcomes in adults. The implementation or cessation of CWF requires careful consideration of this current evidence, in the broader context of a population's oral health, diet and consumption of tap water, movement or migration, and the availability and uptake of other caries-prevention strategies. Acceptability, cost-effectiveness and feasibility of the implementation and monitoring of a CWF programme should also be taken into account.

Adding calcium phosphate agents alongside fluorides may enhance caries prevention and remineralization, although evidence is limited.

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION: Effectiveness of Calcium Phosphate derivative agents on the prevention and remineralization of caries among children- A systematic review & meta-analysis of randomized controlled trials. Singal K, Sharda S, Gupta A, Malik VS, Singh M, Chauhan A, Agarwal A, Pradhan P, Singh M. J Evid Based Dent Pract. 2022; 22(3):101746. SOURCE OF FUNDING: Indian Council of Medical Research. TYPE OF STUDY/DESIGN: Systematic review with meta-analysis.

Interventional clinical trial on mitigating endemic fluorosis in pregnant and lactating ewes with Spirulina platensis and its impact on lamb production traits.

This interventional clinical trial aimed to assess the potential impact of Spirulina platensis supplementation on pregnant and lactating ewes living in a Moroccan endemic fluorosis area. Forty-eight ewes were divided into four equal groups: Groups I and II served as controls belonging respectively to fluorosis-free and endemic fluorosis areas, Groups III and IV received respectively 250 and 500 mg*kg-1 BW/day of S. platensis, during late pregnancy and early lactation. The results revealed that ewes reared in fluorosis-free areas exhibited significantly lower plasma fluoride and significantly higher haemoglobin levels compared to endemic fluorosis areas (P < 0.0001). However, supplementation with 500 mg*kg-1 BW*day-1 of S. platensis significantly improved these two parameters compared to Group II (P < 0.0001). Ewes in the endemic area also displayed increased oxidative stress (P < 0.05), characterized by decreased ascorbic acid levels and catalase activity, as well as elevated levels of reduced glutathione and malondialdehyde. Supplementation with 500 mg*kg-1 BW*day-1 of S. platensis enhanced the antioxidant status (P < 0.05) by increasing ascorbic acid levels and catalase activity and decreasing levels of reduced glutathione and malondialdehyde. Moreover, this dose yielded similar average daily gains compared to lambs of ewes living in fluorosis-free area. In conclusion, S. platensis may serve as a promising solution for addressing endemic fluorosis in pregnant and lactating ewes.

A cross-sectional study of physicians on fluoride-related beliefs and practices, and experiences with fluoride-hesitant caregivers.

The goal of this study was to describe medical providers' fluoride-related beliefs and practices, experiences with fluoride-hesitant caregivers, and barriers to incorporating oral health activities into their practice. In this cross-sectional study, we specifically tested the hypothesis of whether these factors differed between pediatric and family medicine providers. A 39-item online survey was administered to a convenience sample of pediatric and family medicine providers in Washington state and Ohio (U.S.A.). Responses to the fluoride survey were compared between pediatric and family medicine providers with a chi-square test (α = 0.05). Of the 354 study participants, 45% were pediatric providers and 55% were family medicine providers. About 61.9% of providers believed fluoridated water was highly effective at preventing tooth decay while only 29.1% believed prescription fluoride supplements were highly effective. Nearly all providers recommend over-the-counter fluoride toothpaste (87.3%), 44.1% apply topical fluoride in clinic, and 30.8% prescribe fluoride supplements. Most providers reported fluoride hesitancy was a small problem or not a problem (82.5%) and the most common concerns patients raise about fluoride were similar to those raised about vaccines. Lack of time was the most commonly reported barrier to incorporating oral health into practice, which was more commonly reported by family medicine providers than pediatric providers (65.6% vs. 50.3%; p = .005). Pediatric and family medicine providers have early and frequent access to children before children visit a dentist. Improving the use of fluorides through children's medical visits could improve pediatric oral health and reduce oral health inequities, especially for vulnerable populations at increased risk for tooth decay.

Antibacterial and preventive effects of newly developed modified nano-chitosan/glass-ionomer restoration on simulated initial enamel caries lesions: An in vitro study.

BACKGROUND: Despite the superiority of glass-ionomer cements (GICs) over composites in treating white spot lesions (WSLs), there is still a concern about their preventive and antibacterial properties. Efforts have been made to improve the strength of their bond to demineralized enamel, fluoride release and antibacterial properties by adding nanoparticles of chitosan, which seems to be a promising method. OBJECTIVES: The aim of the present study was to assess the antibacterial effect, the microshear bond strength (µSBS) to enamel at the WSL area, and the fluoride and nano-chitosan release after modifying the polyacrylic acid liquid phase of a traditional GIC with different nano-chitosan volumes. MATERIAL AND METHODS: A total of 120 samples were prepared, and then divided into 4 groups (n = 30): G1 - non-modified GIC, which served as a control group, while G2, G3 and G4 were modified with different nano-chitosan volumes (50%, 100% and 150%, respectively). Microshear bond strength was assessed using a universal testing machine (UTM) after storage in distilled water for 24 h. Fluoride and nanochitosan release was measured with the use of spectrophotometers at different time points (initially, and at 1 h, 24 h, 48 h, 72 h, 1 week, 2 weeks, 3 weeks, and 6 weeks) after storage in distilled water. The antibacterial effect against the Streptococcus aureus strain was assessed with the agar diffusion test. The data was statistically analyzed. RESULTS: After 24-hour storage, G2 recorded a slight, yet non-significant, increase in the µSBS values (4.1 ±0.94 MPa) as compared to G1 (3.9 ±1.30 MPa). With regard to fluoride release, the amount recorded for G1 was significantly greater at the end of the 24-hour storage period (0.70 ±0.30 µmf/cm2) than modified nano-chitosan GIC groups; G1 was followed by G4 (0.54 ±0.34 µmf/cm2). The highest amount of nano-chitosan release after 24-hour storage was noted for G3 (0.85 ±0.00 µmf/cm2). The highest inhibition zone value was recorded for G2. CONCLUSIONS: Glass-ionomer cement modified with 50% nano-chitosan was shown to positively affect µSBS and the antibacterial effect, while modification with 150% nano-chitosan significantly increased fluoride release.

[Development of the capacity to communicate risks related to childhood exposure to fluorides through an online educational strategy]. / Desarrollo de la capacidad de comunicar riesgos relacionados con la exposición infantil a fluoruros, a través de una estrategia educativa en línea.

Fluorides are contaminants that occur frequently and, generally, naturally in groundwater, affecting countries that depend on these waters for irrigation and human consumption. Chronic exposure to fluorides generates various health effects; therefore, this research was based on education and risk communication to contribute to the resolution of the problem of fluoride exposure in the population. The objective was to develop the capacity to design risk communication programs for personnel involved in the response and management of environmental health risks, with emphasis on fluoride exposure. An online pilot training course on risk communication and fluoride exposure was designed and implemented. For the analysis of the risk perception and knowledge of the participants, before and after the course, a questionnaire was applied and a focus group was conducted. In addition, the participants carried out a series of activities and designed a risk communication program to assess the degree to which the capacity to develop risk communication programs was achieved. To improve the pilot course, two satisfaction surveys were designed and implemented, and a SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis was conducted. The results showed an increase in the level of knowledge and changes in the participants' perception; regarding the ability to design risk communication programs, two participants were able to design them excellently. Previous experience, motivation, commitment to learn and the feedback provided during the course influenced the development of this ability.

Los fluoruros son contaminantes presentes con frecuencia y generalmente de forma natural en aguas subterráneas, y afectan a países que dependen de estas aguas para el riego y el consumo humano. La exposición crónica a fluoruros genera diversos efectos a la salud; por lo anterior, esta investigación se basó en la educación y la comunicación de riesgos para contribuir a la resolución del problema de exposición a fluoruros en la población. El objetivo fue desarrollar la capacidad de diseñar programas de comunicación de riesgos del personal involucrado en la respuesta y manejo de los riesgos ambientales para la salud, con énfasis en la exposición a fluoruros. Se diseñó e implementó un curso piloto de formación en línea sobre comunicación de riesgos y exposición a fluoruros. Para el análisis de la percepción de riesgos y conocimientos de los participantes, antes y después del curso, se aplicó un cuestionario y se llevó a cabo un grupo focal. Además, los asistentes realizaron una serie de actividades y diseñaron un programa de comunicación de riesgos con el que se valoró el grado en que se alcanzó la capacidad de desarrollar programas de comunicación de riesgos. Para mejorar el curso piloto se diseñaron y aplicaron dos encuestas de satisfacción y se realizó un análisis FODA (Fortalezas, Oportunidades, Debilidades, Amenazas). Los resultados mostraron un incremento en el nivel de conocimientos y cambios en la percepción de los participantes; en cuanto a la capacidad de diseñar programas de comunicación de riesgos, dos participantes lograron diseñarlo de manera excelente. La experiencia previa, la motivación, el compromiso para aprender y la retroalimentación brindada durante el curso, influyeron en el desarrollo de esta capacidad.

Os fluoretos são contaminantes que ocorrem com frequência e, geralmente, de forma natural nas águas subterrâneas, afetando os países que dependem dessas águas para irrigação e consumo humano. A exposição crônica aos fluoretos gera vários efeitos à saúde; portanto, esta pesquisa baseou-se na educação e na comunicação de riscos para contribuir com a solução do problema da exposição ao fluoreto na população. O objetivo foi desenvolver a capacidade de elaborar programas de comunicação de risco para o pessoal envolvido na resposta e no gerenciamento de riscos ambientais à saúde, com ênfase na exposição à fluoretos. Foi elaborado e implementado um curso piloto de treinamento online sobre comunicação de riscos e exposição. Para a análise da percepção de risco e do conhecimento dos participantes antes e depois do curso, foi aplicado um questionário e aplicado um grupo de foco. Além disso, os participantes realizaram uma série de atividades e elaboraram um programa de comunicação de riscos para avaliar até que ponto a capacidade de desenvolver programas de comunicação de riscos foi alcançada. Para aprimorar o curso piloto, foram duas pesquisas de satisfação foram desenvolvidas e implementadas e uma análise FOFA (Forças, Oportunidades, Fraquezas e Ameaças) foi aplicada. Os resultados mostraram um aumento no nível de conhecimento e mudanças nas percepções dos participantes; em termos da capacidade de elaborar programas de comunicação de riscos, dois participantes conseguiram elaborar excelentes programas de comunicação de riscos. A experiência prévia, a motivação, o compromisso com o aprendizado e o feedback fornecido durante o curso influenciaram o desenvolvimento dessa capacidade.

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.

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.

Effectiveness of nanosilver fluoride in arresting dental caries in children with one- year follow-up - a systematic review.

OBJECTIVE: This systematic review assesses the effectiveness of nanosilver fluoride in arresting dental caries in children, with one-year follow-up. METHODOLOGY: Multiple databases were searched for RCTs (randomized controlled trials) according to specified inclusion-exclusion criteria. PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis) reporting guidelines were followed to conduct the systematic review. Nanosilver fluoride was compared against silver diamine fluoride varnish or topical fluoride varnish or placebo. The primary outcome was effectiveness in arresting dental caries. The Cochrane risk of bias tool was used to assess the risk of bias. DATA SOURCES: Articles were searched in the following databases: PubMed, Ovid, Web of Science, Wiley Online, Proquest and Cinahl. DATA SELECTION: The initial search yielded a total of 3660 hits. After deduplication, a total of 2507 articles were obtained. After screening the title and abstract, 11 studies were included. After the full-text screening, a total of three articles that fulfilled the eligibility criteria were included in the analyses. DATA EXTRACTION AND DATA SYNTHESIS: All the three studies were RCTs carried out in school children, and involved application of the material in primary teeth with a follow-up of one year. RESULTS: In two studies, nanosilver fluoride varnish group showed significantly higher arrest of dental caries compared to placebo group. In the study comparing nanosilver fluoride and silver diamine, both the groups showed arrest of dental caries and there was no significant difference between the groups. One study showed high risk of bias for allocation concealment. CONCLUSION: The included studies in the final review effectively demonstrated the benefit of using nanosilver fluoride in the arrest of dental caries.

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.

Enamel Fluoride Uptake Determined Using the Microbiopsy Technique and Time-of-Flight Secondary Ion Mass Spectrometry: A Pilot Study.

This study evaluated the suitability of time-of-flight secondary ion mass spectrometry (ToF-SIMS) to assess enamel fluoride uptake (EFU) in comparison with the microbiopsy technique. Enamel specimens were exposed to equimolar solutions of fluoride prepared from sodium fluoride (NaF), stannous fluoride (SnF2), or amine fluoride (AmF). EFU was quantified by both techniques on the same specimens. EFU was found to be highest for samples treated with AmF, followed by SnF2 and NaF. Both methods yielded clearly interpretable, highly correlating (r = 0.95) data. ToF-SIMS can be considered a promising alternative to the microbiopsy technique for near-surface EFU assessment.

Effects of topical fluoride application on oral microbiota in young children with severe dental caries.

While the effect of fluoride on severe early childhood caries (S-ECC) is clear, knowledge of how it influences the oral microbiota and the consequential effects on oral health is limited. In this cohort study, we investigated the changes introduced in the oral ecosystem before and after using fluoride varnish in 54- to 66-month-old individuals (n=90: 18 children were sampled at 5 different time points). 16S rDNA was amplified from bacterial samples using polymerase chain reaction, and high-throughput sequencing was performed using Illumina MiSeq platforms. Many pronounced microbial changes were related to the effects of fluoride varnishing. The health-associated Bacteroides and Uncultured_bacterium_f_Enterobacteriaceae were enriched in the saliva microbiome following treatment with fluoride varnishing. Co-occurrence network analysis of the dominant genera showed that different groups clearly showed different bacterial correlations. The PICRUSt algorithm was used to predict the function of the microbial communities from saliva samples. The results showed that starch and sucrose metabolism was greater after fluoride use. BugBase was used to determine phenotypes present in microbial community samples. The results showed that Haemophilus and Neisseria (phylum Proteobacteria) was greater before fluoride use. We conclude that the changes in oral microbiology play a role in fluoride prevention of S-ECC.

Dose-response relationship between toothpaste soluble fluoride absorbed in the gastrointestinal tract and saliva fluoride secretion

Aim: This study aimed to evaluate if there is a dose-response relationship between toothpaste chemically soluble fluoride absorbed in the gastrointestinal tract and fluoride secreted by saliva, giving support to the use of saliva as surrogate for plasma fluoride. Methods: A 4-phase single blind study was conducted, in which 10 participants were subjected in each phase to one of the assigned treatment groups: group I: fresh sample of a Na2FPO3/CaCO3-based toothpaste with 1,334 µg F/g of total soluble fluoride (TSF) and groups II­IV: aged samples of this toothpaste presenting TSF concentrations of 1,128, 808, and 687 µg F/g, respectively. In all phases, the participants ingested an amount of toothpaste equivalent to 70.0 µg F/Kg body weight, as total fluoride (TF). Saliva and blood samples were collected before (baseline) and up to 180 min after toothpaste ingestion as indicator of fluoride bioavailability. F concentration in saliva and blood plasma was determined with a fluoride ion-specific electrode. The areas under the curve (AUC) of F concentration versus time (AUC = ng F/mL × min) and the peaks of fluoride concentration (Cmax) in saliva and plasma were calculated. Results: A significant correlation between mg of TSF ingested and the AUC (r=0.47; p<0.01), and Cmax (r=0.59; p<0.01) in saliva was found; for TF, the correlation was not significant (p>0.05). In addition, the correlations between plasma and saliva fluoride concentrations were statistically significant for AUC (r=0.55; p<0.01) as for Cmax (r=0.68; p<0.01). Conclusion: The findings support that saliva can be used as a systemic biomarker of bioavailable fluoride present in Na2FPO3/CaCO3-based toothpaste

Fluoride concentrations in drinking water and health risk assessment in the south of Algeria.

Drinking water is the primary source of fluoride intake by humans worldwide. Algeria, Africa's largest country, has been reported to have moderate to high fluoride levels in the water, particularly in the Southern and Saharan regions. In the south of Algeria, dental fluorosis is considered an epidemic that is spreading within the population by health professionals. This study aimed to determine fluoride concentrations in drinking water consumed by Ouargla population (south-east of Algeria) in 2021, assess non-carcinogenic health risk via daily human intake, and calculate the upper acceptable fluoride concentration in drinking water by Galgan and Vermillion formula. Forty-two water samples were collected during the spring season. The fluoride was measured using a validated spectrophotometric method. Hazard quotient of fluoride (HQ) and estimated daily intake (EDI) were calculated. The results reveal a mean fluoride level of 1.07 ± 0.38 mg/L, below WHO recommendation. Fluoride concentrations in water were higher in rural areas than in the central city (p = 0.05). HQ values were less than one for adults but greater than 1 for infants and children, suggesting health risks associated with water consumption for these vulnerable groups (p = 0.007). The main contribution of this study is the establishment of a database concerning fluoride levels and hazard quotient in the south of Algeria. Monitoring drinking water and control fluorosis is essential to avoid potential health risks.

A Phase 1 Trial to Evaluate the Relationship Between Fluoride Intake and Urinary Fluoride Excretion in Healthy Participants.

Chronic overexposure to fluoride can have deleterious effects in the musculoskeletal system. Some fluorine-containing therapeutics, such as voriconazole, release fluoride through metabolism. Therefore, drug-related fluoride exposure should be assessed for novel therapeutics suspected of releasing fluoride through metabolism. Two trials were conducted to identify the optimal method of assessing drug-related fluoride exposure. In trial 1, designed to assess reproducibility of fluoride pharmacokinetics in urine and plasma, 14 participants were administered a fluoride-restricted diet and once-daily doses of sodium fluoride (2.2 mg [1 mg of fluoride] on days 1 and 2; and 13.2 mg of sodium fluoride [6 mg of fluoride] on days 3 and 4). In trial 2, designed to confirm the selected method for fluoride detection, 12 participants were administered a fluoride-restricted diet and randomized to receive voriconazole (400 mg twice, 12 hours apart, on day 1 [131 mg/d of fluoride maximum], then 3 doses of 200 mg every 12 hours [65.3 mg/d of fluoride maximum]) or placebo. Plasma fluoride concentrations and urinary fluoride excretion were assessed in each trial. Assessment of plasma fluoride concentrations in trial 1 was limited by 301 of 854 samples (35.2%) below the lower limit of quantitation. Urine fluoride excretion was readily measured and demonstrated a decrease from baseline during the fluoride-restricted diet phase, as well as dose-proportional increases with fluoride administration. In trial 2, increases in urine fluoride were successfully observed in participants administered voriconazole. In conclusion, fluoride exposure was optimally assessed by urinary fluoride excretion in conjunction with strict dietary fluoride restrictions, as measurements were consistent and reproducible.

How a Nutritional Deficiency Became Treated with Fluoride.

Ignoring evidence on causes of disease such as smoking can harm public health. This report explores how public health experts started to ignore evidence that pediatric vitamin D deficiencies are associated with dental caries. Historical analyses show that an organization of clinical specialists, the American Dental Association (ADA), initiated this view. The ADA was a world-leading organization and its governing bodies worked through political channels to make fluoride a global standard of care for a disease which at the time was viewed as an indicator of vitamin D deficiencies. The ADA scientific council was enlisted in this endeavor and authorized the statement saying that "claims for vitamin D as a factor in tooth decay are not acceptable". This statement was ghost-written, the opposite of what the ADA scientific council had endorsed for 15 years, and the opposite of what the National Academy of Sciences concluded. Internal ADA documents are informative on the origin of this scientific conundrum; the ADA scientific council had ignored their scientific rules and was assisting ADA governing bodies in conflicts with the medical profession on advertising policies. The evidence presented here suggests that professional organizations of clinical specialists have the power to create standards of care which ignore key evidence and consequently can harm public health.

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.