Guidelines on the use of fluoride for caries prevention in children: an updated EAPD policy document.

AIM: To update the exisitng European Academy of Paediatric Dentistry (EAPD) 2009 fluoride guidelines. METHODS: Experts met in Athens, Greece duirng November 2018 for the following groups: I Fluoride toothpastes, II Fluoride gels, rinses and varnishes, III Fluoridated milk, fluoridated salt, tablets/lozenges and drops, IV Water fluoridation. Systematic reviews and meta-analyses were reviewed and discussed for each of the groups. The GRADE system was used to assess the quality of evidence which was judged as HIGH, MODERATE, LOW or VERY LOW based on the assessment of eight criteria which can influence the confidence of the results. Following the quality assessment, GRADE was then used to indicate the strength of recommendation for each fluoride agent as STRONG or WEAK/CONDITIONAL. RESULTS: Parents must be strongly advised to apply an age-related amount of toothpaste and assist/supervise tooth brushing until at least 7 years of age. The EAPD strongly endorses the daily use of fluoride as a major part of any comprehensive programme for the prevention and control of dental caries in children. Regardless of the type of programme, community or individually based, the use of fluoride must be balanced between the estimation of caries-risk and the possible risks of adverse effects of the fluorides. Fluoride use is considered safe when the manufacturer's instructions are followed. Preventive programmes should be re-evaluated at regular intervals and adapted to a patient's or population's needs and risks. CONCLUSIONS: For the majority of European Countries, the EAPD recommends the appropriate use of fluoride toothpaste in conjunction with good oral hygiene to be the basic fluoride regimen.

The effect on dental enamel of the frequency of consumption of fluoridated milk with a cariogenic challenge in situ.

OBJECTIVES: To evaluate the effect on enamel of varying the frequency of consumption of 1.0 mg F in milk once per day, twice per day or once every other day under cariogenic challenge in situ. MATERIALS AND METHODS: In a controlled, randomised, cross-over, single-blind study, 25 subjects wore an intra-oral lower removable appliance with enamel slabs for 21 days during each study arm. Subjects used F-free toothpaste, the cariogenic challenge comprising of five 2 min dippings per day in a 12% sucrose solution. Subjects dipped the appliances in 50 ml of 5.0 ppm fluoridated milk for five minutes during the test period once per day, twice per day, and once every other day and drank 200 ml of the same milk, once per day, twice per day (100 ml each time), or once every other day (200 ml) immediately on re-inserting their appliance in order to replicate topical and systemic effects. Slabs were analysed with surface microhardness (SMH) for protection against further demineralisation and transverse microradiography (TMR) to assess changes in mineralisation. RESULTS: Using SMH, 200 ml of 5.0 ppm F milk once per day was significantly better than 100 ml of 5.0 ppm F twice/day (p < 0.05) and 200 ml once every other day, but not significantly. Using TMR there was a statistically significant difference in mineral loss of enamel between baseline and treatment for all groups, but not between groups. CONCLUSIONS: Drinking 200 ml of 5.0 ppm milk once per day every day protected enamel against further demineralisation whereas all three frequencies were effective in promoting remineralisation.

Fluoride levels in UK infant milks.

AIM: To provide a comprehensive report of fluoride concentration in UK infant milks and estimate their contribution to daily fluoride intake. METHODS: A total of 60 formula milk products available commercially or within a hospital environment were analysed, along with eight pasteurised cow's milk samples. Formula milk products requiring preparation were reconstituted with fresh Leeds tap water (0.02 ppmF). Fluoride concentration was measured for all products directly using an ion selective electrode after addition of low-level total ionic strength adjustment buffer. RESULTS: The overall median fluoride concentration for the 68 infant milks was 0.025 ppmF, with a wide range of 0.002-0.282 ppmF. Analysis revealed variation between composition and manufacturer, in addition to differences between measured and labeled fluoride concentration. Although all products contained low fluoride concentration, the fluoride concentrations for formula milks used within the hospital setting (0.029 ppmF) were statistically higher in comparison to the commercial formula milk (0.016 ppmF) and cow's milk (0.017 ppmF) products. The daily fluoride contribution from infant milks was low; 0.0034 mgF/kg body weight per day was estimated between birth and 6 months of age, further decreasing as intake of infant milk decreased with age. CONCLUSIONS: Fluoride concentration of the analysed infant milks is low, providing minimal contribution towards total daily F intake and alone are unlikely to pose a threat for the development of dental fluorosis.

Comparison of residual salivary fluoride retention using amine fluoride toothpastes in caries-free and caries-prone children.

AIM: This was to compare the salivary fluoride levels following tooth brushing with amine fluoride toothpastes containing three different concentrations of F (250 ppm F, 500 ppm F and 1250 ppm F) and to evaluate the effect of rinsing with water on the oral fluoride levels up to 90 min. METHODS: A double blind randomised six-arm crossover study was conducted with 32 child participants. Patients were divided into two groups depending on their caries experience with caries-free group (n = 17, mean age = 72.9 months) and caries-prone group (n = 15, mean age = 69.6 months, mean dmfs = 12.3). Each participant brushed their teeth with a smear of dentifrice containing (250 ppm, 500 ppm and 1250 ppm F toothpastes) for 60 s. After spitting out the dentifrice/saliva slurry, participants either rinsed with water or did not rinse at all. Samples of whole mixed unstimulated saliva were collected at 0 (baseline), 1, 15, 30, 45, 60 and 90 mins post-brushing/rinsing. RESULTS: After completing the study on residual fluoride concentration it was found that caries was not a significant variable (p = 0.567) while every other variable was (all p values <0.001). Time, toothpaste F concentration and rinse had significant effects (p < 0.001). In general, higher residual salivary F concentrations were found with increased F concentration in toothpastes and when no rinsing was performed after brushing. CONCLUSION: The results of this study support the current recommendation of using toothpastes with >1000 ppm F concentration in children with an increased caries risk in addition to spitting excess toothpaste with no rinsing following brushing.

Regional Odontodysplasia with Generalised Enamel Defect.

Regional odontodysplasia (ROD) is uncommon developmental anomaly, which tends to be localised and involves the ectodermal and mesodermal tooth components. A five-year-old female was referred to Department of Child Dental Health at the Leeds Dental Institute regarding malformed primary teeth. On examination 64, 74, and 72 had localised hypomineralized enamel defect. The crown of 55 was broken down with only the root remaining below the gingival level. 54 has a yellowish brown discolouration with rough irregular surface. The upper anterior teeth show mild enamel opacity. Radiographically, 55 and 54 had thin radioopaque contour, showing poor distinction between the enamel and dentine and the classic feature of a wide pulp chamber. 15, 16, and 17 were developmentally delayed and were displaying the characteristic "ghost appearance." Comprehensive dental care was done under local anaesthesia and it included extraction of the primary molars affected by ROD, stainless steel crown on 64, and caries prevention program. Fifteen months following the initial assessment the patient's oral condition remains stable and she is under regular follow-up at the department. Paediatric dentists should be aware of this anomaly as it involves both dentitions and usually requires multidisciplinary care.

An unusual presentation of erythema multiforme in a paediatric patient.

BACKGROUND: Erythema multiforme (EM) is an acute, vesiculobullous disease of skin and mucous membranes with symptoms ranging from mild to severe. A complex interaction of different factors has been implicated the condition; the majority with a preceding herpes simplex infection. This report describes an unusual presentation of erythema multiforme affecting the lips and oral mucosa of a healthy 7-year-old boy in the form of lip adherence. CASE REPORT: Two weeks following eruption of oral ulcerations, a 7-year-old healthy boy developed severe erosive ulceration of both lips, causing complete lip adherence. This was accompanied by marked bilateral submandibular and cervical lymphadenopathy, tremor and sweating. Clinical and laboratory investigations led to a diagnosis of erythema multiforme. The patient was treated initially with gentle application of Vaseline between the lips using cotton buds in an attempt to release lip adhesion, followed by surgical release of the lips under general anaesthesia. Analgesics and topical steroid mouthwash were provided. FOLLOW-UP: Seven months later, the patient presented with a recurrence of his EM which included lesions on the skin. The patient was treated with antivirals, topical and systematic steroids to suppress the recurrent attacks of EM. Eighteen months following the initial presentation the patient and parent reported considerable decrease in the frequency, severity and duration of the occurrence of intra-oral ulcers, with no major episode of target lesions on the skin. CONCLUSION: Erythema multiforme is rare in children, however it should be considered in the differential diagnosis of recurrent erosive oral ulcerative lesions especially when the oral lesions resemble those of primary herpetic gingivostomatitis.

A comparison of the presentation of molar incisor hypomineralisation in two communities with different fluoride exposure.

AIM: To compare the clinical presentation of two cohorts of children diagnosed with molar incisor hypomineralisation (MIH) and living in areas of low and high background fluoridation. METHODS: The study population comprised 12-year-old children participating in the 2008-2009 National Dental Epidemiological Programme in five regions in Northern England. Participating dentists were trained and calibrated in the use of the modified Developmental Defects of Enamel Index. Children were examined at school under direct vision with the aid of a dental mirror. First permanent molars and incisors were recorded for the presence and type of enamel defects greater than 2 mm. A diagnosis of MIH was ascribed to any child with a demarcated defect in any first permanent molar. Risk ratios for the occurrence of demarcated, diffuse and hypoplastic defects were generated for MIH children in the fluoridated and non-fluoridated area. RESULTS: 3,233 children were examined. The prevalence of MIH in the fluoridated community was 11 % and in the non-fluoridated community was 17.5 %. Incisors in children with MIH were at greater risk of having demarcated defects (risk ratio 4.0, 3.6-4.5) and diffuse defects (risk ratio 2.2, 2.0-2.5). Molars in children with MIH were at greater risk of diffuse defects (risk ratio 4.4, 3.8-5.0). The teeth of children with MIH living in the fluoridated area were at greater risk of demarcated defects for both incisors (risk ratio 1.6, 1.3-2.0) and molars (risk ratio 1.3, 1.2-1.5) relative to the teeth of MIH children living in the non-fluoridated area. CONCLUSIONS: Children with MIH were at increased risk of both diffuse and demarcated defects in their incisors. Children with MIH living in the fluoridated area were at increased risk of diffuse and demarcated defects relative to MIH children living in the non-fluoridated area.

The prevalence of incisor hypomineralisation and its relationship with the prevalence of molar incisor hypomineralisation.

AIM: To establish the prevalence of incisor hypomineralisation (IH) in a cohort of 12-year-old children in Northern England and to relate the prevalence to gender, socioeconomic status, and the prevalence of molar incisor hypomineralisation (MIH). METHOD: The study population comprised 12-year-old children participating in the 2008-2009 National Dental Epidemiological Programme in five regions in Northern England. Participating dentists were trained and calibrated in the use of the modified Developmental Defects of Enamel Index. Children were examined at school under direct vision with the aid of a dental mirror. First permanent molars and incisors were recorded for the presence and type of enamel defects greater than 2 mm. A diagnosis of MIH was ascribed to any child with a demarcated defect in any first permanent molar. A diagnosis of IH was ascribed to any child with a demarcated defect in an incisor but with molar sparing. RESULTS: 3,233 children were examined. The prevalence of IH was 11.0 % (95 % CI 11.0-12.2 %). There was a strong positive correlation between the prevalence of MIH and IH in different regions which reached significance (r = 0.9, p = 0.037) according to Spearman's rho test of correlation. There was a similar pattern of prevalence in the different socioeconomic quintiles although this correlation did not reach significance. The most common teeth affected in IH were the maxillary central incisors, followed by the maxillary lateral incisors and followed by the mandibular incisors. There was no difference in the prevalence of IH by gender. CONCLUSIONS: The prevalence of IH was 11.0 %. The variation of prevalence between regions and socioeconomic groups and the distribution of lesions in the teeth were very similar to observations seen in MIH children from the same cohort.

Barriers to dental care for children with autism spectrum disorder.

AIMS: This study examined the problems encountered by children with autism spectrum disorder (ASD), when accessing dental care. STUDY DESIGN: This was a cross-sectional, case-control questionnaire study. METHODS: A piloted questionnaire was developed to identify the main barriers to dental care experienced by patients with ASD in Hull and East Riding. The study group was comprised of parents/carers of children with ASD, and the control group was comprised of parents/carers of age matched healthy, neurotypical children. STATISTICS: Results were analysed using Chi-square and Fisher's exact tests where appropriate. Significance was deemed at p < 0.05. Ordinal data was presented using medians and 25th and 75th centiles and compared using Mann-Whitney U test. METHODS: A piloted questionnaire was developed to identify the main barriers to dental care experienced by patients with ASD in Hull and East Riding. The study group was comprised of parents/carers of children with ASD, and the control group was comprised of parents/carers of age matched healthy, neurotypical children. RESULTS: 112 subjects completed the questionnaire. There was no significant difference in accessing dental care between study and control groups (p = 0.051), although access was perceived as more difficult in the ASD group (p < 0.001). There was a significantly greater perceived difficulty in travelling to the dental surgery in the ASD group. Predicted negative behaviours were more frequent in the ASD group. All suggested interventions were predicted to be helpful in a significantly greater proportion of the ASD group. CONCLUSION: Difficulties exist for children with ASD in accessing dental care in the Hull and East Riding area.

The effect of varying concentrations of fluoridated milk on enamel remineralisation in vitro.

The aim of this in vitro single blind study was to investigate the dose response of fluoride in milk on enamel demineralisation and remineralisation under pH cycling using transverse microradiography (TMR). Enamel slabs (n = 11) with caries-like lesions were exposed to milk containing 6 different fluoride concentrations (0, 0.25, 0.5, 1.0, 5.0 and 10.0 ppm F). On each of the 14 days of the cycling period the lesions were exposed to five 2-minute periods of cariogenic challenge (1.5 mM CaCl2, 0.9 mM KH2PO4 and 50 mM acetic acid at pH 5.0) and two 5-min periods in milk plus 10 min in a milk/saliva (1:3) slurry. The slabs were stored at 37°C in artificial saliva throughout the cycling period and demineralisation and remineralisation was assessed by TMR using dedicated image software. Remineralisation (ΔZ) was observed in all fluoride groups in contrast to demineralisation in the non-fluoride control. Remineralisation was significant (p < 0.05) for all concentrations above 1.0 ppm F. The results showed that fluoride concentration in milk exhibited a clear dose dependency and that the presence of fluoride even at low concentrations promoted remineralisation in this pH-cycling model.

The effect on dental enamel of varying concentrations of fluoridated milk with a cariogenic challenge in situ.

OBJECTIVES: This study investigated the effect of two concentrations of fluoride in milk, 2.5 and 5.0 ppm, on the prevention of demineralisation with a cariogenic challenge compared with milk with 0 ppm F. METHODS: In a controlled, randomised, cross-over, double-blind in situ study, 23 subjects wore a lower removable appliance with 2 enamel slabs for 21 days during each study arm. Subjects used F-free toothpaste and the cariogenic challenge comprised of five 2 min dippings per day in 12% sucrose. The slabs were dipped in 50 ml of milk with 0 ppm, 2.5 ppm or 5.0 ppm F twice daily for 5 min. Subjects drank 100ml twice per day of the same milk. Slabs were analysed with Knoop microhardness to assess changes in mineralisation. RESULTS: Results showed that enamel was softened in all groups but the extent of enamel softness was reduced with an increasing concentration of F in milk, being highly significant for both F groups compared to the control (p<0.0001). 5.0 ppm F group showed a trend towards less softening compared to the 2.5 ppm F but was not statistically significant. CONCLUSIONS: In our in situ model, 2.5 and 5.0 ppm F in milk significantly protected enamel from demineralisation.

Comparison of the effects of whole and juiced fruits and vegetables on enamel demineralisation in situ.

We compared the effect on enamel demineralisation in situ of both whole and juiced fruits and vegetables. Volunteers wore removable mandibular appliances carrying pre-demineralised human enamel slabs and consumed one of the test foods 7 times a day for 10 days. The test foods were apples, oranges, grapes, carrots, and tomatoes, consumed either whole (sugars located intrinsically) or as a juice (extrinsic or free sugars). Raisins containing 64% sugars, but intrinsic by definition, were also studied. The mineral profile of the enamel slabs was studied before and after the test period using transverse microradiography and showed further demineralisation for all test foods, irrespective of the form of consumption. Significant demineralisation was also observed with raisins. No significant differences were found between the solid and juiced foods. In conclusion, sugars present intrinsically on consumption had a similar demineralising potential as free sugars and could not be considered less cariogenic.

The effect of fluoride slow-releasing devices on fluoride in plaque biofilms and saliva: a randomised controlled trial.

AIM: To investigate the effect of the fluoride sustained slow-releasing device (FSSRD) on F levels in unstimulated saliva and undisturbed plaque biofilms over 7 days. The investigation also aimed at studying the effect of patient age on fluoride (F) concentrations in dental plaque biofilms and unstimulated saliva while using the FSSRD. STUDY DESIGN: This was a randomised control double blind cross-over study. METHODS: Sixty-five participants between the ages of 6-35 years took part in this study. The mean age of all the participants was 19.22 years with 24 participants aged between 6-16 years (mean age=11.8 years) and 41 participants aged between 16-35 years (mean age=23.57 years). Plaque biofilms were collected using a modification of the plaque generating device (MPGD) [Robinson et al., 1997]. During the whole study period, including a 7 day washout period before the first leg, all participants were asked to use only non-fluoridated toothpaste and to avoid where possible high fluoride containing foods or drinks. Whenever possible, the FSSRD/placebo device (PD) was attached to the second permanent molar, while the MPGD was attached to the first permanent molars in the same upper dental quadrant. At the end of each leg of the study whole, mixed unstimulated saliva was collected from all participants and analysed for F concentration. STATISTICS: Statistical analysis using paired sample t-test was used to compare the results of F level between test and control groups, while, Spearman's correlation coefficient was used to test the relationship between patient's age and plaque weight against F concentration in plaque and saliva. RESULTS: There was no statistically significant difference in F concentration in plaque and saliva between the test and control groups when analysed using paired sample t-test (p>0.05). There was no correlation between patient's age and F concentration in dental plaque and saliva (p>0.05), in both the test and control groups. CONCLUSIONS: Our data showed no effect of the FSSRD in raising F concentrations in dental plaque and unstimulated whole saliva after 7 days. Such levels may require longer periods to become established.

Effect of slow-release fluoride devices and casein phosphopeptide/amorphous calcium phosphate nanocomplexes on enamel remineralization in vitro.

To investigate the remineralization effect of slow-release fluoride glass devices (SFGD), casein phosphopeptide/amorphous calcium phosphate nanocomplexes (CPP-ACP) and SFGD and CPP-ACP together on enamel pH cycling in vitro. Eighty bovine enamel slabs were allocated to each of 4 groups (20/group): SFGD; CPP-ACP; SFGD + CPP-ACP; control. Baseline surface microhardness (SMH; Knoop number) was measured for all slabs which were then subjected to a pH cycling regime for 10 days, and SMH was then remeasured. The pH cycling regime involved immersion 5 times daily (each for 5 min) in demineralization solution with the slabs immersed in artificial saliva between dipping. The treatment for the enamel slabs in the SFGD group involved exposure all the time to 2 SFGD devices per group during the cycling regime. In contrast, slabs in the CPP-ACP group were exposed to CPP-ACP slurry once daily for 30 min after the last demineralization challenge of the day. The slabs in the SFGD + CPP-ACP group received both treatments as the SFGD and CPP-ACP groups. The control group received no treatment during the cycling. There was a statistically significant difference in enamel SMH change among the groups (one-way ANOVA; p < 0.0001). Enamel SMH values in the SFGD, CPP-ACP and SFGD + CPP-ACP groups were all significantly higher than in the control group (Bonferroni; p < 0.0001). There was no significant difference in enamel SMH between the SFGD and CPP-ACP groups (p > 0.05). The use of both SFGD + CPP-ACP showed a non-significant trend for improvement in enamel SMH in comparison to SFGD or CPP-ACP alone.

In vitro and in vivo assessment of newly developed slow-release fluoride glass device.

BACKGROUND: The concept of constant and low levels of F intra-orally has been applied in dentistry using a controlled release delivery system in different forms of slow-release F intra-oral devices. AIM: To investigate the effect of newly shaped plastic brackets on the level of fluoride released by the devices in vitro and to compare the level of fluoride released by unilateral versus bilateral slow-release fluoride glass devices in adults in vivo. STUDY DESIGN: The phase I, in vitro assessment involved 15 slow-release fluoride glass devices divided into three groups. Group A contained five glass beads, Group B, five fluoride devices placed with the plastic brackets facing down, and Group C, five fluoride devices placed with the plastic brackets facing up. Evaluation of fluoride release was carried out daily for a week, weekly for a month, and monthly for 18 months. The In vivo phase II involved 20 adults (mean age 29.7+/-2.3 years) randomly divided and had unilateral or bilateral slow-release fluoride glass devices placed for six months. RESULTS: Groups A and B released fluoride for up to ten months. In Group C, the glass beads became loose at the end of the first month and were excluded from further analysis. There was no statistical significant difference in the mean of total fluoride released by Groups A and B. All participants showed higher salivary fluoride levels than at baseline. There was no statistically significant difference in the level of fluoride released by the bilateral and unilateral groups. CONCLUSIONS: The newly shaped slow-release fluoride glass devices showed continuous, safe, and effective fluoride release.

A review of slow-release fluoride devices.

BACKGROUND: Fluoride has been used to combat dental caries using a number of different clinical approaches. An exciting relatively new development is fluoride slow-releasing devices that consistently elevate intra-oral fluoride levels of plaque and saliva for prolonged periods of up to two years. METHODS: The literature on the use of slow-releasing fluoride devices in dentistry were reviewed. A Medline search on key words was carried out. All papers in English were individually reviewed. RESULTS: Slow-releasing fluoride devices have been shown to be effective in elevating salivary fluoride levels in both animals and human studies and to enhance the remineralisation of dental enamel. They have been demonstrated to be safe to use and without the risk of fluoride toxicity. A double blind randomised clinical trial demonstrated 76% fewer new carious surface increment in high caries-risk children after two years. CONCLUSIONS: These devices have a number of potential uses in dentistry and in particular have great potential for caries prevention of non-compliant high caries-risk groups.