**6. Discussion**

196 Contemporary Approach to Dental Caries

Fig. 3. dmf-t index in children under 6 years old: Metaview.

Fig. 4. Odds ratios to dental caries prevalence in children under 14 years old: Metaview.

Fluoride concentrations used in toothpastes are an important factor concerning toothpaste efficacy in reducing dental caries. Literature reviews such as the one done by Richards et al.(28) conclude that the optimal fluoride concentration in toothpaste is 1000 ppm F. This concentration has shown to provide best benefits in reducing dental caries and fluorosis. Meanwhile with fluoride concentrations less than 1000 ppm the efficacy in the reduction of dental caries is diminished (29).

Recently, some meta-analysis has been published to describe the efficacy of different fluoride concentrations used in toothpastes to prevent dental caries in children and teenagers (1,20,21,33). However, none of them obtained conclusions regarding toothpastes with 440 and 550 ppm F.

There were a limited number of studies comparing low F (440 to 550 ppm) to high F (1000 or more ppm) toothpastes. For this meta-analysis only five studies were found, out of which four were selected.

The total sample size of children under 14 years old included in the 4 selected studies was 5657, the fluoride compounds in the toothpastes used were sodium fluoride in 440, 500, 550 and 1450 ppm; and sodium monofluorophosphate in 1000, 1055 and 1450 ppm, as they are the most used in general population.

Effect of 1000 or More ppm Relative

knowledge of these circumstances.

about dental caries incidence and dental fluorosis.

toothpastes is justified, in high caries risk children.

evidence in this topic.

mothers and the newborn.

2003;37:85-92.

**7. References** 

to 440 to 550 ppm Fluoride Toothpaste – A Systematic Review 199

These results are an approach to answer the question of the efficacy of low fluoride toothpastes (considered for reducing fluorosis risk in children) in reducing dental caries

The fact that low fluoride concentration toothpaste is currently being recommended for children younger than 6 years old without enough scientific evidence must concern the scientific community, as the impact is greater in the population which does not have

This study did not attempt to report possible adverse effects of fluoride toothpaste like dental fluorosis. Although some authors state that concentrations of 440 a 550 ppm F reduce the risk of developing dental fluorosis (19), there is a lack of clinical assays and cohort studies to confirm said hypothesis, leading to a lack of major clinical evidence in relation to the efficacy of low fluoride toothpaste in reducing dental caries in children younger than 6 years old and its impact on this population. This systematic review, increases the available

Recommendations for specific fluoride doses in toothpastes requires combined studies

In order to learn the epidemiological significance of the clinical difference between these fluoride concentrations, it would be beneficial to promote community studies with different systemic fluoridation levels and high caries risk groups that would allow for the evaluation of fluorosis risk and caries risk, in order to more firmly establish if the use of low fluoride

The concentration of fluoride in toothpaste is a protective factor for dental caries but is clear that in children less than 5 years is a risk factor for dental fluorosis. Dental caries is the most common chronic disease of childhood and continues been a public health concern (4,11,12,26,31). For dental caries management and disease control in children under 5 years the emphasis must be focus in other than fluoride concentration, is important to propos combined preventive approaches providing early access to dental services, medical approaches, no operative intervention and specific educational and informational actions for

Recent Meta-analysis and clinical trials confirm the great effect of high concentration fluoride dental toothpaste (36). Although 6% sounds little its effect must not be underestimated, mainly in this age group when the relation between dental toothpaste

[1] Ammari AB, Bloch-Zupan A, Ashley PF. Systematic review of studies comparing the

[2] Burt BA, Keels MA, Heller KE. The effects of a break in water fluoridation on the development of dental caries and fluorosis. J Dent Res 2000;79:761-769.

anti-caries efficacy of children´s toothpaste containing 600 ppm of fluoride or less with high fluoride toothpastes of 1000 ppm or above. Caries Res

quantity and fluoride concentration combination could be important and pertinent.

incidence in a population in which dental caries is still a public health problem.

Winter et al. (37) reported the first clinical controlled trial in children under 2 years old followed during three years. All included trials in comparison experienced relative high percentage of subjects at baseline who dropped out during the course of studies. However in all of these studies they considered this at the moment of the sample size estimation. Davies et al (10) were the only ones to report the reason for these drop outs.

In some cases it was necessary to contact the author to obtain additional data ( DMF-T) such as the Biesbrock et al.(6) study in order to compare it with the other three studies.

The diagnostic system used in all the studies was the DMF and dmf indices at the level of cavity (D3) (16,25); The Biesbrock study was the only one that included opacity lesion with microcavity data in their analysis (D2) (16,25). Regardless of some authors considering that there may be some differences between primary and permanent enamel in reactivity to caries challenges (1,32), this is not clear. Thus we combined primary and permanent dentition.

Some clinical studies have shown that with 1000 to 2500 ppm F toothpaste an increase of 6% is obtained in dental caries protection for each 500 ppm (23,35).

Combined evidence from the included assay suggest that toothpastes with concentrations of 1000 ppm and more are more effective in caries reduction, showing a higher prevalence of dental caries in children under 6 years who used lower fluoride concentrations (440 to 550 ppm) toothpastes. It is important to note that precisely the group of children younger than 6 years is the main consumer of this toothpaste because this is the group in which traditional 1000 ppm F toothpaste is being replaced.

The results of this meta-analysis show that 440 to 550 ppm F toothpaste is less effective in preventing dental caries than 1000 ppm F toothpaste, and it is interesting to note that it is necessary to double the fluoride concentration to have a risk difference of only 6%. Similar results were reported by Amari et al.(1), as they found a caries Indexes Weighted Mean Difference of 0.6 between dental toothpastes with 250 ppm F and 1000 ppm F, and they emphasized that a fourfold increase in F concentration is necessary to obtain such a difference.

Twetman et al.(30) reported for daily use of fluoride toothpaste compared to placebo in the young permanent dentition (Prevented Fraction: 24.9%) and for toothpastes with 1500ppm F compared with standard toothpaste with 1000 ppm F in young permanent dentition( PF 9,7%), These were greater than the results of this meta-analysis where PF, expressed as percentage, was 6% in favor of 1000 ppm F as was expected.

Despite the fact that there were few studies included, it is important to note the homogeneity found between them as well as the quality even considering studies like Winter et al.(37) and Reed(27) which date back to 13 and 30 years respectively.

Similar conditions of the included studies related to variables as the non-public water or salt fluoridation and their participation in health supervised programs are in favor of the obtained results.

As there were a limited numbers of studies, asymmetry was difficult to asses, by funnel plot. However, comparing their sample size, the Biesbrock et al. (6) study, which had lowest sample size (n=349) did not alter the combined estimation of the effect when it was withdrawn from the sensibility analysis.

Winter et al. (37) reported the first clinical controlled trial in children under 2 years old followed during three years. All included trials in comparison experienced relative high percentage of subjects at baseline who dropped out during the course of studies. However in all of these studies they considered this at the moment of the sample size estimation.

In some cases it was necessary to contact the author to obtain additional data ( DMF-T) such

The diagnostic system used in all the studies was the DMF and dmf indices at the level of cavity (D3) (16,25); The Biesbrock study was the only one that included opacity lesion with microcavity data in their analysis (D2) (16,25). Regardless of some authors considering that there may be some differences between primary and permanent enamel in reactivity to caries challenges (1,32), this is not clear. Thus we combined primary and permanent

Some clinical studies have shown that with 1000 to 2500 ppm F toothpaste an increase of 6%

Combined evidence from the included assay suggest that toothpastes with concentrations of 1000 ppm and more are more effective in caries reduction, showing a higher prevalence of dental caries in children under 6 years who used lower fluoride concentrations (440 to 550 ppm) toothpastes. It is important to note that precisely the group of children younger than 6 years is the main consumer of this toothpaste because this is the group in which traditional

The results of this meta-analysis show that 440 to 550 ppm F toothpaste is less effective in preventing dental caries than 1000 ppm F toothpaste, and it is interesting to note that it is necessary to double the fluoride concentration to have a risk difference of only 6%. Similar results were reported by Amari et al.(1), as they found a caries Indexes Weighted Mean Difference of 0.6 between dental toothpastes with 250 ppm F and 1000 ppm F, and they emphasized that a fourfold increase in F concentration is necessary to obtain such a difference. Twetman et al.(30) reported for daily use of fluoride toothpaste compared to placebo in the young permanent dentition (Prevented Fraction: 24.9%) and for toothpastes with 1500ppm F compared with standard toothpaste with 1000 ppm F in young permanent dentition( PF 9,7%), These were greater than the results of this meta-analysis where PF, expressed as

Despite the fact that there were few studies included, it is important to note the homogeneity found between them as well as the quality even considering studies like

Similar conditions of the included studies related to variables as the non-public water or salt fluoridation and their participation in health supervised programs are in favor of the

As there were a limited numbers of studies, asymmetry was difficult to asses, by funnel plot. However, comparing their sample size, the Biesbrock et al. (6) study, which had lowest sample size (n=349) did not alter the combined estimation of the effect when it was

Winter et al.(37) and Reed(27) which date back to 13 and 30 years respectively.

Davies et al (10) were the only ones to report the reason for these drop outs.

is obtained in dental caries protection for each 500 ppm (23,35).

percentage, was 6% in favor of 1000 ppm F as was expected.

1000 ppm F toothpaste is being replaced.

withdrawn from the sensibility analysis.

dentition.

obtained results.

as the Biesbrock et al.(6) study in order to compare it with the other three studies.

These results are an approach to answer the question of the efficacy of low fluoride toothpastes (considered for reducing fluorosis risk in children) in reducing dental caries incidence in a population in which dental caries is still a public health problem.

The fact that low fluoride concentration toothpaste is currently being recommended for children younger than 6 years old without enough scientific evidence must concern the scientific community, as the impact is greater in the population which does not have knowledge of these circumstances.

This study did not attempt to report possible adverse effects of fluoride toothpaste like dental fluorosis. Although some authors state that concentrations of 440 a 550 ppm F reduce the risk of developing dental fluorosis (19), there is a lack of clinical assays and cohort studies to confirm said hypothesis, leading to a lack of major clinical evidence in relation to the efficacy of low fluoride toothpaste in reducing dental caries in children younger than 6 years old and its impact on this population. This systematic review, increases the available evidence in this topic.

Recommendations for specific fluoride doses in toothpastes requires combined studies about dental caries incidence and dental fluorosis.

In order to learn the epidemiological significance of the clinical difference between these fluoride concentrations, it would be beneficial to promote community studies with different systemic fluoridation levels and high caries risk groups that would allow for the evaluation of fluorosis risk and caries risk, in order to more firmly establish if the use of low fluoride toothpastes is justified, in high caries risk children.

The concentration of fluoride in toothpaste is a protective factor for dental caries but is clear that in children less than 5 years is a risk factor for dental fluorosis. Dental caries is the most common chronic disease of childhood and continues been a public health concern (4,11,12,26,31). For dental caries management and disease control in children under 5 years the emphasis must be focus in other than fluoride concentration, is important to propos combined preventive approaches providing early access to dental services, medical approaches, no operative intervention and specific educational and informational actions for mothers and the newborn.

Recent Meta-analysis and clinical trials confirm the great effect of high concentration fluoride dental toothpaste (36). Although 6% sounds little its effect must not be underestimated, mainly in this age group when the relation between dental toothpaste quantity and fluoride concentration combination could be important and pertinent.
