**Effect of 1000 or More ppm Relative to 440 to 550 ppm Fluoride Toothpaste – A Systematic Review**

Alexandra Saldarriaga Cadavid1, Rubén Darío Manrique Hernández2 and Clara María Arango Lince3 *1Faculty of Odontology, Pediatric Dentistry and Epidemilogy, Research Department, 2Department of Epidemiology, 3Faculty of Odontology, Pediatric Dentistry Department,* 

> *CES University, Medellín Colombia*

#### **1. Introduction**

During the last three decades a significant worldwide reduction – of dental caries has been observed. Experts agree that fluoride in its multiple presentations has played an important role, together with changes in oral hygiene habits among different populations. Fluoride toothpastes has gained interest as a relevant strategy in prevention because of its important role in dental caries reduction, that can reach up to 40% (7,8,14). However, at the same time, they have contributed to an increase in the prevalence of dental fluorosis in children. There is concern about dental fluorosis related to the chronic intake of excessive quantities of fluoride in children under 6 years of age. Some authors have reported that the early use of fluoridated toothpastes in young children is a very important risk factor (13,17,22,33,34). Beside fluoride concentration, the duration and age of exposure are important factors in fluorosis prevalence (2).

In order to reduce the risk of dental fluorosis, the use of toothpaste with 440 to 550 ppm F in children less than six years old has been recommended (5). The efficacy of these toothpastes in reducing dental caries is still unknown and controversialy among the scientific community (1,3). In Colombia, the fluoride concentration of toothpastes for preschool children below the age of 6 years was limited several years ago to 500 ppm in order to control dental fluorosis.

According to the Oral Health National Study (NSOH III)(13), the prevalence of dental fluorosis in Colombian children between 6 and 7 years old is 25.7%. The highest prevalence of moderate and severe dental fluorosis was found in Bogotá with 4.5% of the children being affected. Another study carried out in 2002 in four Colombian cities, to evaluate fluoride intake in 2 to 4 year olds from meals, beverages and toothpastes reported that in all cities except one, the total fluoride intake was above optimal limits (0.07 mgF/Kg of body weight) and even some were above the risk limit (0.1 mgF/Kg of body weight). From the three

Effect of 1000 or More ppm Relative

Leonard, Piel Cochrane Group(18).

had a score of 70% from 100 possible points (24).

Study Reason for exclusion

brand that distributes toothpastes in Colombia.

evaluation, the following procedures were followed:

modifications were done on individuals.

Table 2. Excluded studies

**3. Data analysis** 

reported.

to 440 to 550 ppm Fluoride Toothpaste – A Systematic Review 193

was calculated using the standard error which was obtained from confidence interval

Ammari et al. (1) did not include both the Winter et al. (37) and Reed(27) trials. They argued high drop out percentages (29% and 28% respectively) and lack of explanation for these drop-outs. However, they included a drop-out percentage in their sample size estimation. For the characteristic description of the studies found initially, the reviewers used an information extraction format, based on the format developed by Sally Hollis y Tina

The Chalmers criteria were used to evaluate the quality of these studies accepting those that

The methodological procedure used to evaluate the studies consisted of an individual review by each examiner to verify the quality criteria of each study that complied with the inclusion criteria and graded them in a scorecard design for each of the different content indicators of the instrument. Afterwards, the research group evaluated as a team and assigned individual points to each study, trying to reach a consensus around those in which noticeable differences existed (assigned extreme values). A design format was used to total the final scores of each study. Studies that scored at least 70% were included in the final

meta analysis. One trial could not be included in the meta-analysis (see Table2).

Holt, 1994(19) Although groups to compare acomplished inclusion criteria, this

This study was free of any conflict of interest, given that no company or pharmaceutical laboratory sponsored its execution, and its final result was not related to any commercial

According to the Antioquia Health Secretary's resolution 008430 of 1993, this project was considered a "non risk investigation". It includes literature review techniques and no intervention or intended biological, physiological, psychological or social variable

In addition to the complete reading of each of the included articles and its quality

Mantel-Haenzel test of homogeneity was used to evaluate the null hypothesis that the included studies were homogeneous. Statistical calculations were carried out following the Mantel-Haenzel Q heterogeneity statistical formula. This test was compared with Chi square distribution with n-1 degrees of freedom and a confidence level of 95%, where n was the number of studies included in the meta analysis, which in this case was n=4. If under these circumstances the calculated QMH value was above the tabulated value of X2, the

study used the sample and data of a previous study (Winter, 1989). It was considered a secondary analysis of the mentioned study

studied sources, the lowest fluoride intake was from beverages at 4.3%, followed by meals at 26%. The highest fluoride intake came from toothpastes which comprised 69% of the total ingested fluoride (15).

The use of 500 ppm fluoride pastes raised the question of how effective this toothpaste is compared with the 1000 or more ppm F toothpastes, in the prevention of dental caries.

Therefore, the aim of this study was to carry out a quantitative systematic review assessing the efficacy of toothpastes with low fluoride concentrations between 440 and 550 ppm in the reduction of dental caries in children under 14 years old compared to toothpastes that contain 1000 or more ppm F.
