Anna-Karin Holm

Caries-preventive effect of fluoride toothpaste: a systematic review

With a questionnaire addressed to general dental practitioners in Sweden, the Swedish Council on Technology Assessment in Health Care launched a project group in 1999 to systematically review and evaluate the existing literature on various caries preventive methods. The aim of this article was to report findings concerning the caries preventive effect of fluoride toothpastes in various age groups, with special emphasis on fluoride concentration and supervised versus non‐supervised brushing. A systematic search in electronic databases for articles published between 1966 and April 2003 was conducted with the inclusion criteria of a randomized or controlled clinical trial, at least 2 years follow‐up and caries increment in the permanent (ΔDMFS/T) or primary (Δdmfs/t) dentition as endpoint. Out of 905 articles originally identified, 54 met the inclusion criteria. These studies were assessed independently by at least two reviewers and scored A–C according to predetermined criteria for methodology and performance. The measure of effect was the prevented fraction (PF), expressed as percent. The results revealed strong evidence (level 1) (i) for the caries preventive effect of daily use of fluoride toothpaste compared to placebo in the young permanent dentition (PF 24.9%), (ii) that toothpastes with 1,500 ppm of fluoride had a superior preventive effect compared with standard dentifrices with 1,000 ppm F in the young permanent dentition (PF 9.7%), and (iii) that higher caries reductions were recorded in studies with supervised toothbrushing compared with non‐supervised (PF 23.3%). However, incomplete evidence (level 4) was found regarding the effect of fluoride toothpaste in the primary dentition. In conclusion, this review reinforced the importance of daily toothbrushing with fluoridated toothpastes for preventing dental caries, although long‐term studies in age groups other than children and adolescents are still lacking.

Caries-preventive effect of fissure sealants: a systematic review

The objectives of this study were to evaluate systematically the evidence of the caries‐preventive effect of fissure sealing of occlusal tooth surfaces and to examine factors potentially modifying the effect. The search strategies included electronic databases, reference lists of articles, and selected textbooks. Inclusion criteria were randomized or quasi‐randomized clinical trials or controlled clinical trials comparing fissure sealing with no treatment or another preventive treatment in children up to 14 years of age at the start; the outcome measure was caries increment; the diagnostic criteria had been described; and the follow‐up time was at least 2 years. Inclusion decisions were taken and grading of the studies was done independently by two of the authors. The main measure of effect was relative risk reduction. Thirteen studies using resin‐based or glass ionomer sealant materials were included in the final analysis. The results showed that most studies were performed during the 1970s and a single application had been utilized. The relative caries risk reduction pooled estimate of resin‐based sealants on permanent 1st molars was 33% (relative risk=0.67; CI=0.55-0.83). The effect depended on retention of the sealant. In conclusion, the review suggests limited evidence that fissure sealing of 1st permanent molars with resin‐based materials has a caries‐preventive effect. The evidence is incomplete for permanent 2nd molars, premolars and primary molars and for glass ionomer cements. Overall, there remains a need for further trials of high quality, particularly in child populations with a low and a high caries risk, respectively.

TMD in relation to malocclusion and orthodontic treatment

OBJECTIVE The aim of this systematic literature review was to evaluate associations between different malocclusions, orthodontic treatment, and signs and symptoms of temporomandibular disorders (TMD). MATERIALS AND METHODS This review was part of a project at the Swedish Council on Technology Assessment in Health Care focusing on malocclusion and orthodontic treatment from a health perspective. As a first step, the literature was searched in the Medline and Cochrane Library databases from 1966 to May 2003. A later update was made in January 2005. Human studies in English or in Scandinavian languages were included. RESULTS Associations between certain malocclusions and TMD were found in some studies, whereas the majority of the reviewed articles failed to identify significant and clinically important associations. TMD could not be correlated to any specific type of malocclusion, and there was no support for the belief that orthodontic treatment may cause TMD. Obvious individual variations in signs and symptoms of TMD over time according to some longitudinal studies further emphasized the difficulty in establishing malocclusion as a significant risk factor for TMD. A considerable reduction in signs and symptoms of TMD between the teenage period and young adulthood has been shown in some recent longitudinal studies. CONCLUSIONS Associations between specific types of malocclusions and development of significant signs and symptoms of TMD could not be verified. There is still a need for longitudinal studies.

Long-term stability of orthodontic treatment and patient satisfaction. A systematic review.

OBJECTIVE To evaluate morphologic stability and patient satisfaction at least 5 years after orthodontic treatment. MATERIALS AND METHODS Published literature was searched through the PubMed and Cochrane Library electronic databases from 1966 to January 2005. The search was performed by an information specialist at the Swedish Council on Technology Assessment in Health Care. The inclusion criteria consisted of a follow-up period of at least 5 years postretention; randomized clinical trials, prospective or retrospective clinical controlled studies, and cohort studies; and orthodontic treatment including fixed or removable appliances, selective grinding, or extractions. Two reviewers extracted the data independently and also assessed the quality of the studies. RESULTS The search strategy resulted in 1004 abstracts or full-text articles, of which 38 met the inclusion criteria. Treatment of crowding resulted in successful dental alignment. However, the mandibular arch length and width gradually decreased, and crowding of the lower anterior teeth reoccurred postretention. This condition was unpredictable at the individual level (limited evidence). Treatment of Angle Class II division 1 malocclusion with Herbst appliance normalized the occlusion. Relapse occurred but could not be predicted at the individual level (limited evidence). The scientific evidence was insufficient for conclusions on treatment of cross-bite, Angle Class III, open bite, and various other malocclusions as well as on patient satisfaction in a long-term perspective. CONCLUSIONS This review has exposed the difficulties in drawing meaningful evidence-based conclusions often because of the inherent problems of retrospective and uncontrolled study design.

Changes in the oral microflora in patients with acute leukemia and related disorders during the period of induction therapy

The present study reports changes occurring within the oral microflora in 20 patients with leukemia during and after the period of high-dose cytotoxic therapy. The relationship between the presence of enterobacteria, yeast cells, and staphylococci and the occurrence of oral ulcers/angular cheilitis was also studied. To make a comparison, three groups of patients without malignant disorders (acute disorders, long-term hospitalization, antibiotic treatment) were also studied. The total number of salivary microorganisms remained unchanged during the period. Fourteen of twenty patients with leukemia harbored enterobacteria on at least one occasion. No differences were found in the number of enterobacteria before, during, and after treatment with cytotoxic or antimicrobial drugs. Enterobacteria were also found in the reference group with long-term hospitalization, but seldom in the other reference groups. Staphylococci and lactobacilli were present in all patients in the leukemia group and in the majority in the reference groups. Yeast cells were found in 80% of the patients with leukemia. Patients with ulcers and/or angular cheilitis had higher numbers of yeast cells than the other patients. There was no relationship between enterobacteria or staphylococci and oral lesions.

Economic evaluation of dental caries prevention: a systematic review.

The aim of the present study was to perform a systematic review of economic evaluations of caries prevention. A search in Medline from 1966 until May 2003 and a manual search in a number of journals identified 154 references, 74 of which were included. There were 17 original studies including an economic evaluation, and these form the basis of the present article. The rest were reviews, model studies and reports concerning economic practice in dentistry. The results show that the reviewed original studies on economic evaluation of caries prevention do not provide support for the economic value of caries prevention. The scarcity of well‐conducted studies, as well as contradictory evidence in the reviewed articles, makes it difficult to judge the health‐economic effect of the studied caries‐prevention methods.

Dental health, dental care, and dietary habits in children in different parts of Sweden

An epidemiological study of dental health, dental health care, and sociodemographic data in 817 4-, 8-, and 13-year-old children was carried out in 1980/81 in two areas in the county of Västerbotten, northern Sweden, and in one area in the northern part of the county of Alvsborg, in southwestern Sweden. Dietary habits and nutrient intake were studied in 738 of the children. The aim of the study was to examine the dental health in the different areas and to study the importance of variations in related background factors. The results showed great differences in dental health in all age groups between the two counties. There were also differences between the two areas in the north, but these were not as evident. A discriminant function analysis showed that age when organized dental care started and tooth-brushing frequency had greater explanatory power on dental caries than food habit factors.

Effect of combined caries-preventive methods: a systematic review of controlled clinical trials.

The aim of this systematic review was to evaluate the caries‐preventive effect of combined caries‐preventive methods, defined as two or more different interventions in combination, each expected to prevent dental caries. The Medline database was searched for articles published in the period January 1966 to June 2003. Twenty‐four controlled studies met the inclusion criteria, and their value as evidence was assessed according to predetermined criteria. The level of evidence for the overall conclusion regarding each method was graded according to the protocol of the Swedish Council on Technology Assessment in Health Care. The scientific evidence for the combination of treatments involving fluoride that had a preventive effect on caries in children and adolescents was graded as moderate. However, for elderly patients the scientific evidence for the caries‐preventive effect of different combinations of treatments was found to be incomplete. No conclusion could be drawn regarding the evidence for combinations of treatments being effective for groups at high caries risk, as the results from the identified clinical studies were conflicting.

A descriptive and comparative study of oral health in 8-year-old Swedish children.

The aim of the study was to assess the oral health of a group of children, and to compare the findings with the results from an investigation performed 4 years earlier in children of the same age and living in the same area. The material consisted of 149 randomly selected 8-year-old children. The study included examination of caries and the state of the gingival conditions, enamel hypoplasia and opacities, supragingival calculus and extrinsic stains. Determinations were also made of the rate of secretion, pH and buffer effect of stimulated saliva. Socio-economic data and anamnestic dental data were noted. The investigation showed a decrease in caries frequency in the primary teeth, but not in the permanent teeth, during the four-year-period. As in the former investigation, regression analyses showed a negative correlation between the level of education of the parents and caries indices, and that the variation of the gingival indices could be explained by socio-economic factors. In addition, a negative correlation was found between the caries index for primary teeth and the rate of secretion of the saliva and the presence of supragingival calculus.

Saliva tests in the prognosis of caries in children.

The purpose of the investigation was to find out whether the negative correlations between caries indices and the flow rate, pH and buffer effect of saliva that could be demonstrated in groups of 8- and 5-year-old children, were close enough to allow prediction of the development of caries in a given child. The results showed that the range of variation of the results of all analyses were very wide. This makes the use of saliva tests alone in the prognosis of caries development of less value in the individual child.