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
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.
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.
Sponsors
The Canadian Task Force on Preventive Health
Care developed this guideline with funding from Health Canada.
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.