CTF Structured Abstract: Prevention of dental caries

Canadian Task Force on Preventive Health Care

Structured Abstract

Please note: In 2003, the CTF updated its Grades of Recommendations to include an "I Recommendation" for situations where insufficient evidence exists to allow a recommendation to be made. (Formerly, these situations were captured under a "C Recommendation".) This change is not retroactive, and all "C Recommendations" made prior to 2003 have not been reevaluated in light of the new "I" recommendation grade. For a discussion of these recommendation grades, please link to the 2003 article in the Canadian Medical Association Journal here.

Prevention of Dental Caries

Prepared by Donald W. Lewis, DDS, DDPH, MScD, FRCDC, Department of Community Dentistry, Univerity of Toronto, and Amid I. Ismail, BDS, MPH, DrPH, Department of Pediatric & Community Dentistry, Dalhousie University

These recommendations were finalized by the Task Force in September 1993

Objective
Burden of Suffering
Options
Outcomes

Evidence
Values
Benefits, Harms, and Costs
Recommendations

Validation
Sponsors
Selected References

Objective

To make recommendations about primary prevention of dental caries in all age groups in Canada.

Burden of Suffering

Dental caries is a localized, progressive demineralization of the hard tissues of the crown and root surfaces of teeth. Dental caries results from the interplay of three main factors over time: dietary carbohydrates, cariogenic bacteria with dental plaque, and susceptible hard tooth surfaces. Although current data is lacking, older data suggest that caries incidence had three peaks: at about age 7 for coronal decay of the primary dentition; at about age 14 for coronal decay of the permanent dentition; and, for root surface decay, incidence began at about age 30-40 years with steady increases thereafter. The incidence and prevalence of dental caries have declined in the industrialized countries over the last 20 years, with Canadian children now having 33-50% lower dental caries prevalence and many children having experienced no decay or fillings at all. Age, socioeconomic status and past dental caries are strongly linked with dental caries incidence, yet oral hygiene as practiced by most people is not strongly related to dental caries occurrence. Children and adults with special medical problems (those with bulimia or Sjogren's syndrome, and those receiving therapeutic head and neck radiation, chemotherapy, or prolonged treatment with drugs that reduce salivary flow) are at a higher risk for dental caries. Institutionalized and physically and mentally disabled persons are also at higher risk for dental caries. The financial burden of diagnosing, preventing, treating and retreating dental disease, particularly dental caries, is great. Canadian dental care costs in 1989 were estimated at $3.1 billion, representing a tripling of dental care costs since 1979.

Options

Use of fluorides, fissure sealants, dietary counselling and oral hygiene.

Outcomes

Main outcome is the presence/absence of coronal or root dental caries.

Evidence

Data sources included a literature search from 1980 to 1992 and significant review articles. The database searched and keywords for searching were not specified.

Recommendations were graded as:

A Good evidence to support the recommendation that the condition be specifically considered in a PHE.

B Fair evidence to support the recommendation that the condition be specifically considered in a PHE.

C Poor evidence regarding inclusion or exclusion of the condition in a PHE, but recommendations may be made on other grounds.

D Fair evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.

E Good evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.

Quality of evidence was rated according to 5 levels:

I Evidence from at least 1 properly randomized controlled trial (RCT).

II-1 Evidence from well-designed controlled trials without randomization.

II-2 Evidence from well-designed cohort or case-control analytic studies, preferably from more than 1 centre or research group.

II-3 Evidence from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments could also be included here.

III Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees.

Values

The 13-member Task Force of experts in family medicine, geriatric medicine, pediatrics, psychiatry and epidemiology used an evidence-based method for evaluating the effectiveness of preventive health care interventions. Recommendations were not based on cost-effectiveness of options. Patient preferences were not discussed.

Background papers providing critical appraisal of the evidence and tentative recommendations prepared by the chapter author were pre-circulated to the members. Evidence for this topic was presented and deliberated upon in 1- to 2-day meetings, 2 to 3 times per year from June 1992 to September 1993. Consensus was reached on final recommendations.

Benefits, Harms, and Costs

Evidence from controlled trials without randomization shows that water fluoridation is the "single, most effective, equitable and efficient means of preventing coronal and root dental caries".

RCTs have shown that self-applied and professionally-applied fluoride dentifrices are effective in preventing coronal and root caries. Advantages of self-applied fluoride toothpastes are ease of use and low cost. Because of the widespread availability of fluoride in various forms, there is an increased risk of mild fluorosis in children, which is not unsightly, but does suggest excess fluoride intake.

Resins applied by dental personnel to pit and fissure surfaces of posterior teeth have been intensively tested in RCTs, and found to be effective in reducing surface decay. Reductions in the incidence of caries, the high cost of resins and differential tendencies for certain fissures to decay are considerations for use.

Routine counselling to reduce sucrose intake and replace with 'safe' substitutes does not appear to be useful. Two recent longitudinal cohort studies found that dental caries incidence was low among children despite high sugar consumption. In one study, sugar intake was related only to decay of smooth surfaces between teeth, but even this has decreased in recent years. There is, however, a high risk of severe decay in infants' teeth caused by nocturnal or prolonged use of bottles of liquids other than water. The effectiveness of counselling in changing behaviour is unclear.

There is no evidence that removal of plaque by brushing (with a non-fluoride toothpaste), flossing, or prophylaxis preceding a dental exam decreases the incidence of caries. Daily oral hygiene does help to control gingival disease, and is necessary for the application of fluoride toothpaste.

Recommendations

Recommendation grade [A, B, C, D, E] and level of evidence [I, II-1, II-2, II-3, III] are indicated after each recommendation. Citations in support of individual recommendations are identified in the guideline text.

There is good evidence to recommend daily fluoride supplements only in geographic locations where water fluoride levels are sub-optimal and if the proper dosage schedule is carefully followed [A, II-1].
There is good evidence to recommend professionally-applied topical fluorides for patients at high risk, and only where water fluoride levels are less than optimal [A, I].
There is good evidence for the application of fluoride toothpaste as part of regular oral hygiene. Young children should be supervised to prevent excess swallowing of toothpaste. [A, I]
There is poor evidence to include daily plaque removal by brushing and flossing [C, III], but brushing is required for self-application of fluoride toothpaste [A, I] and for prevention of gingivitis [B, II-1].
There is good evidence for selective use of fissure sealants on recently-erupted permanent molars in children at high risk for caries [A, I].
There is poor evidence that dietary changes are effective for the general population [C, II-2]. Counselling of individuals at high risk, and regarding nocturnal use of bottles with infants may be clinically prudent.

Validation

This report was externally peer-reviewed. Comparison with recommendations by other agencies were not described.

Selected References

Source Document

Lewis DW and Ismail AI. Prevention of dental caries. In: Canadian Task Force on the Periodic Health Examination. Canadian Guide to Clinical Preventive Health Care. Ottawa: Health Canada, 1994; 408-17.

Link to Full Text of this review

Link to Summary Table of Recommendations of this review

Link to Selected References list of this review

Link to 1995 update: Prevention of dental caries

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A	Good evidence to support the recommendation that the condition be specifically considered in a PHE.
B	Fair evidence to support the recommendation that the condition be specifically considered in a PHE.
C	Poor evidence regarding inclusion or exclusion of the condition in a PHE, but recommendations may be made on other grounds.
D	Fair evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.
E	Good evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.

I	Evidence from at least 1 properly randomized controlled trial (RCT).
II-1	Evidence from well-designed controlled trials without randomization.
II-2	Evidence from well-designed cohort or case-control analytic studies, preferably from more than 1 centre or research group.
II-3	Evidence from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments could also be included here.
III	Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees.