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This is a plain English summary of an original research article. The views expressed are those of the author or reviewers at the time of publication.
Providing a set of fluoride-based supplements at dental appointments for two- to three-year-olds was no better than health education in preventing tooth decay. A number of public health measures are also needed to reduce sugar consumption.
Treatment included providing fluoride toothpaste and applying a fluoride varnish to the teeth at every six-monthly appointment for three years.
This large NIHR-funded trial in Northern Ireland found no difference in the number of children developing tooth decay, although children in the treatment arm had fewer teeth showing signs of tooth decay. The estimated cost was ÂŁ2,093 per child prevented from caries.
The minimal effect reported in this study must be interpreted in light of the population-level benefits achieved with fluoride products to date. In addition, children from more deprived areas were more likely to develop caries and may be more likely to benefit from fluoride products. These children were underrepresented in this study.
Dentists should continue to follow Public Health England guidance and offer all children advice on fluoride products. It seems that eating healthy and especially reducing sugar consumption may also be part of the solution.
Why was this study needed?
Around a third of 5-year-olds in England, Wales and Northern Ireland have tooth decay (cavities) in their primary (baby) teeth. Children with tooth decay experience pain and are more likely to need tooth extractions, at a significant cost to the NHS.
Tooth decay occurs when bacteria in the mouth break down dietary sugars, producing acids that erode tooth enamel. Fluoride toothpastes, mouthwashes and varnishes have been shown to inhibit this process.
Guidance from Public Health England recommends that dentists offer all children advice on the use of fluoride products, oral hygiene and a healthy diet, such as avoiding sugary drinks.
However, this advice has improved dental health or social inequalities in outcomes as much as hoped. So these researchers were interested to see if providing extra fluoride through varnish and free toothpaste to these children was more effective and cost-effective.
What did this study do?
This study evaluated whether a comprehensive fluoride intervention delivered by dentists was effective in preventing caries in young children. This randomized controlled trial recruited 1248 children aged 2–3 years from 22 NHS dental practices in Northern Ireland. All children were free of caries at the start of the study.
Half of the children were randomly assigned to receive the fluoride intervention. This included applying fluoride varnish to the teeth and providing free fluoride toothpaste and toothbrushes at every six-monthly check-up for three years. They also received dental health education about optimal use of toothpaste and limiting sugar consumption. Control group parents received health education alone.
The study had a large sample size and a good follow-up rate, with approximately 86% of children attending each six-monthly check-up. Assessors were unaware of group allocation. However, the study had a limited scope to understand all the behaviors that might affect the results.
What did he find?
- The fluoride-based intervention was no better than health education alone in preventing caries. About a third of children in both the intervention group (34%) and the control group (39%) developed caries in at least one tooth during the three-year study period (odds ratio 0.81, 95% confidence interval 0.64 to 1.04).
- Among children who developed caries, the mean number of affected tooth surfaces was significantly lower in the intervention group (7.2) than the control group (9.6). Adjusted mean difference 2.29 fewer surfaces (95% CI 3.96 to 0.63 fewer). Toothache was more common among children who developed caries compared with those who did not, but there was no difference in pain rates between study groups.
- There was little difference between groups in reported adverse events (7.2% of the intervention group vs. 5.9% of controls), and most adverse events were considered unrelated to treatment. However, 10 children in the intervention group experienced minor effects attributable to the treatment, including abdominal discomfort.
- The average total cost per child over the three-year study (including the cost of the intervention and any other dental care) was ÂŁ1,027 in the intervention group and ÂŁ816 in the control group. The cost of the intervention to prevent caries in one child was ÂŁ2,093.
- Across all participants, children in the most deprived areas were more likely to develop caries than those in the least deprived areas (44% vs. 28%).
What does current guidance say about this?
NICE guidance for oral health promotion for general dental practices (2015) recommends that all patients (or their parents or carers) be counseled during dental examinations, including advice on fluoride use, oral hygiene and diet.
Public Health England 2014 prevention toolkit for dental health professionals recommends that children up to six years of age brush their teeth twice a day with fluoride toothpaste. Children aged 3-6 years or younger if there are dental problems should be offered fluoride varnish applied to their teeth twice a year. The frequency and amount of sugary foods and drinks should be reduced.
Northern Ireland has an oral health strategy published in 2007 and this recommends that the prevention of tooth decay in children, particularly among those from disadvantaged backgrounds, should be a key health objective for all Councils and Trusts in Northern Ireland. Northern Ireland does not have a water fluoridation scheme.
What are the consequences;
Fluoride-based therapy had little effect on caries prevention which was of questionable clinical benefit. However, the study was conducted in a context of recent population-level improvements in dental health as a result of fluoride-based interventions.
Children from the most disadvantaged areas were underrepresented in this study. Practice-based interventions may not be able to reach high-risk populations.
Alternative community-based interventions, such as the distribution of fluoride toothpaste through the mail, may have greater potential to reach disadvantaged groups. However, whether such strategies provide value for money in caries prevention in young children should be considered.
Two approaches seem to be needed to improve children’s dental health, ensuring regular brushing with fluoride and reducing intake of sugar and sugary drinks. Fluoride varnish can add little to these actions.
Reporting and funding
Tickle M, O’Neill C, Donaldson M, et al. A randomized controlled trial to measure the effects and costs of a dental caries prevention regime for young children attending primary care dental services: the Northern Ireland Caries Prevention in Practice (NIC-PIP) trial. Health Technology Assessment. 2016? 20 (71): 1-96.
This project was funded by the National Institutes of Health Research’s Health Technology Assessment program (project number 08/14/19).
Bibliography
DHSSPS. Oral Health Strategy for Northern Ireland. Belfast: Department of Health, Social Services and Public Safety. 2007.
NHS Options. Children’s teeth. London: Department of Health; 2015.
NHS Digital. Child Dental Health Survey 2013, England, Wales and Northern Ireland. Leeds: NHS Digital; 2015.
BEAUTIFUL. Oral health promotion for general dental practices. London: National Institute for Health and Care Excellence. 2015.
Public Health England. Delivering better oral health: an evidence-based toolkit for prevention. London: Public Health England; 2014.
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