May Cm Wong

Topical fluoride as a cause of dental fluorosis in children

BACKGROUNDnFor many years, topical use of fluorides has gained greater popularity than systemic use of fluorides. A possible adverse effect associated with the use of topical fluoride is the development of dental fluorosis due to the ingestion of excessive fluoride by young children with developing teeth.nnnOBJECTIVESnTo describe the relationship between the use of topical fluorides in young children and the risk of developing dental fluorosis.nnnSEARCH STRATEGYnElectronic search of the Cochrane Oral Health Group Trials Register, CENTRAL, MEDLINE, EMBASE, BIOSIS, Dissertation Abstracts and LILACS/BBO. Reference lists from relevant articles were searched. Date of the most recent searches: 9th March 09.nnnSELECTION CRITERIAnRandomised controlled trials (RCTs), quasi-RCTs, cohort studies, case-control studies and cross-sectional surveys, in which fluoride toothpastes, mouthrinses, gels, foams, paint-on solutions, and varnishes were compared to an alternative fluoride treatment, placebo or no intervention group. Children under the age of 6 years at the time topical fluorides were used.nnnDATA COLLECTION AND ANALYSISnData from all included studies were extracted by two review authors. Risk ratios for controlled, prospective studies and odds ratios for case-control studies or cross-sectional surveys were extracted or calculated. Where both adjusted and unadjusted risk ratios or odds ratios were presented, the adjusted value was included in the meta-analysis.nnnMAIN RESULTSn25 studies were included: 2 RCTs, 1 cohort study, 6 case-control studies and 16 cross-sectional surveys. Only one RCT was judged to be at low risk of bias. The other RCT and all observational studies were judged to be at moderate to high risk of bias. Studies were included in four intervention/exposure comparisons. A statistically significant reduction in fluorosis was found if brushing of a childs teeth with fluoride toothpaste commenced after the age of 12 months odds ratio 0.70 (random-effects: 95% confidence interval 0.57 to 0.88) (data from observational studies). Inconsistent statistically significant associations were found between starting using fluoride toothpaste/toothbrushing before or after the age of 24 months and fluorosis (data from observational studies). From the RCTs, use of higher level of fluoride was associated with an increased risk of fluorosis. No significant association between the frequency of toothbrushing or the amount of fluoride toothpaste used and fluorosis was found.nnnAUTHORS CONCLUSIONSnThere should be a balanced consideration between the benefits of topical fluorides in caries prevention and the risk of the development of fluorosis. Most of the available evidence focuses on mild fluorosis. There is weak unreliable evidence that starting the use of fluoride toothpaste in children under 12 months of age may be associated with an increased risk of fluorosis. The evidence for its use between the age of 12 and 24 months is equivocal. If the risk of fluorosis is of concern, the fluoride level of toothpaste for young children (under 6 years of age) is recommended to be lower than 1000 parts per million (ppm).More evidence with low risk of bias is needed. Future trials assessing the effectiveness of different types of topical fluorides (including toothpastes, gels, varnishes and mouthrinses) or different concentrations or both should ensure that they include an adequate follow-up period in order to collect data on potential fluorosis. As it is unethical to propose RCTs to assess fluorosis itself, it is acknowledged that further observational studies will be undertaken in this area. However, attention needs to be given to the choice of study design, bearing in mind that prospective, controlled studies will be less susceptible to bias than retrospective and/or uncontrolled studies.

Relationship between children’s oral health-related behaviors and their caregiver’s sense of coherence

BackgroundSense of coherence (SOC) is hypothesized to be an important psychological factor that enables people to cope with stressors and successfully maintain and improve health. Mother’s SOC has been shown to be an important psychological factor associated with oral health and oral health-related behaviors of adolescents and 11- to 12-year-old children. However, little is known about the relationship between the caregiver’s SOC and oral health-related behaviors of the preschool children. The objective of this study was to investigate the relationship between oral health-related behaviors of 5-year-old children in Southern China and SOC of their caregiver.MethodsA cross-sectional study was conducted in a randomized sample of 1332 children aged 5 years and their caregivers in Guangzhou, Southern China. Data were collected through questionnaires completed by the caregivers. The Chinese short version of Antonovsky’s SOC scale (13 items) was employed to assess the caregiver’s SOC. The outcome variables were the child’s oral health-related behaviors, including frequency of sugary snack intake, toothbrushing frequency, utilization of dental service, and pattern of dental visits. Multiple logistic regression was used to analyze the relationship between the variables.ResultsNo association was found between the children’s sugary snack intake and the mother’s or the father’s SOC. After adjustment for other significant factors related to the child’s oral health-related behaviors, 8.9% of the children whose grandparents (as caregivers) had higher SOC scores had a lower frequency of sugary snack intake, compared with the children whose grandparents had lower SOC scores (ORu2009=u20090.61, 95% CIu2009=u20090.50–0.73, pu2009=u20090.008). The other measures of oral health-related behaviors of the child were not significantly associated with the caregiver’s SOC.ConclusionSugary snack intake behavior of the 5-year-old children was not associated with the mother’s or the father’s SOC. It was associated with the SOC of their grandparents, who are a small group of the caregivers in China.

Arresting Dentine Caries with Different Concentration and Periodicity of Silver Diamine Fluoride

Different regimens of silver diamine fluoride (SDF) have been used to manage early childhood caries. So far, there is limited information regarding the concentrations and frequency of applications for effective caries control in primary teeth. This study aimed to compare the efficacy of 2 commercially available SDF solutions at preprepared concentrations of 38% and 12% when applied annually or biannually over 18 mo in arresting dentine caries in primary teeth. This randomized double-blinded clinical trial recruited kindergarten children aged 3 to 4 y who had at least 1 tooth with dentine caries. The children were randomly allocated to receive 4 treatment protocols: group 1, annual application of 12% SDF; group 2, biannual application of 12% SDF; group 3, annual application of 38% SDF; and group 4, biannual application of 38% SDF. Clinical examinations at 6-mo intervals were conducted to assess whether active carious lesions became arrested. Information on the children’s background and oral hygiene habits was collected through a parental questionnaire at baseline and follow-up examinations. A total of 888 children with 4,220 dentine carious tooth surfaces received treatment at baseline. After 18 mo, 831 children (94%) were examined. The caries arrest rates were 50%, 55%, 64%, and 74% for groups 1, 2, 3, and 4, respectively ( P < 0.001). Lesions treated with SDF biannual application had a higher chance of becoming arrested compared with those receiving SDF annual application (odds ratio, 1.33; 95% confidence interval, 1.04–1.71; P = 0.025). The interaction between concentration and lesion site was statistically significant ( P < 0.001). Compared with 12% SDF, the use of 38% SDF increased a chance of becoming arrested ( P < 0.05), except lesions on occlusal surfaces. Based on the 18-mo results, SDF is more effective in arresting dentin caries in the primary teeth of preschool children at 38% concentration than 12% concentration and when applied biannually rather than annually. Knowledge Transfer Statement: The results of this study can be used by clinicians and dental public health professionals when deciding which concentrations and frequency of application of silver diamine fluoride solution should be adopted for arresting dentine caries. With consideration of caries arrest treatment with silver diamine fluoride, which is painless, simple, and low cost, this information could lead to more appropriate therapeutic decisions for caries control in young children or those who lack access to affordable conventional dental care.

Randomized Clinical Trial of 12% and 38% Silver Diamine Fluoride Treatment:

This 30-mo randomized clinical trial compared the effectiveness of 2 concentrations (12% or 38%) of silver diamine fluoride (SDF) and 2 periodicity of application (once or twice a year) in arresting cavitated dentin caries in primary teeth. Children aged 3 to 4 y who had at least 1 active cavitated caries lesion were enrolled and randomly allocated into 4 groups for intervention. Group 1 had 12% SDF applied annually (every 12 mo), group 2 had 12% SDF applied semiannually (every 6 mo), group 3 had 38% SDF applied annually, and group 4 had 38% SDF applied semiannually. Clinical examinations were performed semiannually in kindergarten by a single examiner to investigate whether the SDF-treated caries became arrested. A total of 888 children with 4,220 decayed tooth surfaces received SDF application at baseline, and 799 (90.0%) children with 3,790 surfaces (89.8%) were evaluated at the 30-mo examination. The caries arrest rates were 55.2%, 58.6%, 66.9%, and 75.7% for groups 1, 2, 3, and 4, respectively (P < 0.001). Caries treated with 38% SDF had a higher chance of becoming arrested than those treated with 12% SDF (odds ratio [OR], 1.98; 95% confidence interval [CI], 1.51–2.60, P < 0.001). The interaction between frequency of SDF application and visible plaque index (VPI) score was significant (P = 0.017). Among those children who received annual SDF application, children with a higher VPI score had a lower chance to have their caries become arrested (OR, 0.59, 95% CI, 0.49–0.72). In conclusion, SDF at a concentration of 38% is more effective than that of 12% in arresting active caries in primary teeth. For children with poor oral hygiene, caries arrest rate of SDF treatment can be increased by increasing the frequency of application from annually to semiannually (ClinicalTrials.gov NCT02385474).

Arresting Early Childhood Caries with Silver Diamine Fluoride-A Literature Review

Conventional restorative management of early childhood caries (ECC) is unlikely to tackle this prevalent disease, and arresting caries treatment using silver diamine fluoride (SDF) has become a pragmatic strategy, particularly for young and apprehensive children. Arrested caries is clinically characterized by its increase in hardness and a dark brown to black coloration. Subsequent restorative procedures can be carried out if necessary. This review article discusses the rationale of arresting caries treatment, mechanism of action of SDF, and safety and complications of SDF treatment. A literature search using PubMed was performed to review the clinical trials using SDF to manage ECC. Results found 6 clinical trials published in English since 1980. The studies suggested that one-off application of 12% SDF is not effective in arresting caries in children, but 38% SDF is. The main disadvantage of SDF treatment is black staining of the arrested lesion, but significant complications were not reported. In general, the studies concluded that topical application of SDF is a simple and low cost method to arrest ECC. This treatment strategy therefore increases access for children in developing countries to receive affordable dental treatment.

Adverse Effects of Silver Diamine Fluoride Treatment among Preschool Children

This randomized clinical trial aimed to compare the adverse effects and parental satisfaction following the different regimes of silver diamine fluoride (SDF) treatment among preschool children. A total of 888 preschool children who had active dentin caries received different SDF application regimes: group 1, 12% SDF applied annually; group 2, 12% SDF applied semiannually; group 3, 38% SDF applied annually; and group 4, 38% SDF applied semiannually. Information on adverse effects—including tooth or gum pain, gum swelling, gum bleaching, and systemic toxicity—was collected through a parent-reported questionnaire within 1 wk after every SDF or placebo application. Information of parental satisfaction on children’s dental appearance was collected at baseline and 30-mo examination. At the 30 mo, 799 children (90%) remained in the study. No acute systemic illness or major adverse effect was reported. No differences of all minor adverse effects among the 4 groups were found (P > 0.05). Overall, prevalence of tooth and gum pain as perceived by patients and reported by parents was 6.6%, while gum swelling and gum bleaching were 2.8% and 4.7%, respectively. Blackening of carious lesions was common among all groups, with 36.7%, 49.5%, 65.6% and 76.3% in groups 1 to 4, respectively (χ2 test, P < 0.001). The proportion of parents who were satisfied with their children’s dental appearance in groups 1 to 4 was as follows: 67.6%, 61.5%, 70.8%, and 62.3%, respectively (χ2 test, P > 0.05). Based on parental reporting, SDF does not cause acute systemic illness. Tooth or gum pain, gum swelling, and gum bleaching were uncommon and not significantly different among the study groups. Parental satisfaction with children’s dental appearance was similar among all groups. The use of SDF following the study protocol for caries arrest is safe for preschool children. Collecting information on parental satisfaction and adverse effects is beneficial for dental professionals when deciding to adopt SDF treatment for preschool children (ClinicalTrials.gov NCT02385474).

Rubber dam isolation for restorative treatment in dental patients

BACKGROUNDnSuccessful restorations in dental patients depend largely on the effective control of moisture and microbes during the procedure. The rubber dam technique has been one of the most widely used isolation methods in dental restorative treatments. The evidence on the effects of rubber dam usage on the longevity of dental restorations is conflicting. Therefore, it is important to summarise the available evidence to determine the effects of this method.nnnOBJECTIVESnTo assess the effects of rubber dam isolation compared with other types of isolation used for direct and indirect restorative treatments in dental patients.nnnSEARCH METHODSnWe searched the following electronic databases: Cochrane Oral Healths Trials Register (searched 17 August 2016), Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 7) in the Cochrane Library (searched 17 August 2016), MEDLINE Ovid (1946 to 17 August 2016), Embase Ovid (1980 to 17 August 2016), LILACS BIREME Virtual Health Library (Latin American and Caribbean Health Science Information database; 1982 to 17 August 2016), SciELO BIREME Virtual Health Library (1998 to 17 August 2016), Chinese BioMedical Literature Database (CBM, in Chinese) (1978 to 30 August 2016), VIP (in Chinese) (1989 to 30 August 2016), and China National Knowledge Infrastructure (CNKI, in Chinese) (1994 to 30 August 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform, OpenGrey and Sciencepaper Online (in Chinese) for ongoing trials. There were no restrictions on the language or date of publication when searching the electronic databases.nnnSELECTION CRITERIAnWe included randomised controlled trials (including split-mouth trials) assessing the effects of rubber dam isolation for restorative treatments in dental patients.nnnDATA COLLECTION AND ANALYSISnTwo review authors independently screened the results of the electronic searches, extracted data and assessed the risk of bias of the included studies. We resolved disagreement by discussion.nnnMAIN RESULTSnWe included four studies that analysed 1270 participants (among which 233 participants were lost to follow-up). All the included studies were at high risk of bias. We excluded one trial from the analysis due to inconsistencies in the presented data.The results indicated that dental restorations had a significantly higher survival rate in the rubber dam isolation group compared to the cotton roll isolation group at six months in participants receiving composite restorative treatment of non-carious cervical lesions (risk ratio (RR) 1.19, 95% confidence interval (CI) 1.04 to 1.37, very low-quality evidence). It also showed that the rubber dam group had a lower risk of failure at two years in children undergoing proximal atraumatic restorative treatment in primary molars (hazard ratio (HR) 0.80, 95% CI 0.66 to 0.97, very low-quality evidence). One trial reported limited data showing that rubber dam usage during fissure sealing might shorten the treatment time. None of the included studies mentioned adverse effects or reported the direct cost of the treatment, or the level of patient acceptance/satisfaction. There was also no evidence evaluating the effects of rubber dam usage on the quality of the restorations.nnnAUTHORS CONCLUSIONSnWe found some very low-quality evidence, from single studies, suggesting that rubber dam usage in dental direct restorative treatments may lead to a lower failure rate of the restorations, compared with the failure rate for cotton roll usage. Further high quality research evaluating the effects of rubber dam usage on different types of restorative treatments is required.

The effectiveness of the biannual application of silver nitrate solution followed by sodium fluoride varnish in arresting early childhood caries in preschool children: study protocol for a randomised controlled trial

BackgroundThe application of 38xa0% silver diamine fluoride (SDF) has been shown to be effective in arresting early childhood caries (ECC). Since SDF is not available in certain countries, some dentists use adjunctive application of 25xa0% silver nitrate (AgNO3) and 5xa0% sodium fluoride (NaF) to arrest ECC. This randomised controlled trial will systematically compare the efficacy of a 25xa0% AgNO3 solution followed by 5xa0% NaF varnish with that of a 38xa0% SDF solution in arresting ECC when applied at half-yearly intervals over a 30-month period.Methods/DesignThis study is a randomised, double-blinded, non-inferiority clinical trial. The hypothesis tested is that adjunctive application of 25xa0% AgNO3 followed by 5xa0% NaF is at least not appreciably worse than a 38xa0% SDF in arresting ECC. Approximately 3100 kindergarten children aged 3–4 years will be screened and at least 1070 children with caries will be recruited. This sample size is sufficient for an appropriate statistical analysis (power at 90xa0% (βu2009=u20090.10) with a 2-sided type-I error of αu2009=u20090.05), allowing for an overall 20xa0% drop-out rate. The children will be randomly allocated into 2 groups to treat their caries over a 30-month period:Group A – biannual adjunctive application of a 25xa0% AgNO3 solution and a 5xa0% NaF varnish, andGroup B – biannual adjunctive application of a 38xa0% SDF solution followed by a placebo varnish.Clinical examinations will be conducted at 6-month intervals. Primary outcome measured is the number of active caries surfaces which are arrested. Information on confounding factors such as oral hygiene habits will be collected through a parental questionnaire.DiscussionWe expect that adjunctive application of 25xa0% AgNO3 solution and 5xa0% NaF varnish and of 38xa0% SDF solution can both effectively arrest ECC. Lower concentrations of silver and fluoride are contained in 25xa0% AgNO3 and 5xa0% NaF, respectively, than in 38xa0% SDF; therefore, AgNO3/NaF are more favourable for use in young children. Because its use for caries management is painless, simple, low-cost, and approved in many countries, AgNO3/NaF could be widely recommended and promoted as an alternative treatment to conventional invasive management of ECC.Trial registrationClinicalTrials.gov: NCT02019160. Date of registration: 11 December 2013.

Evaluation of psychometric properties and differential item functioning of 8-item Child Perceptions Questionnaires using item response theory

BackgroundFour-factor structure of the two 8-item short forms of Child Perceptions Questionnaire CPQ11–14 (RSF:8 and ISF:8) has been confirmed. However, the sum scores are typically reported in practice as a proxy of Oral health-related Quality of Life (OHRQoL), which implied a unidimensional structure. This study first assessed the unidimensionality of 8-item short forms of CPQ11–14. Item response theory (IRT) was employed to offer an alternative and complementary approach of validation and to overcome the limitations of classical test theory assumptions.MethodsA random sample of 649 12-year-old school children in Hong Kong was analyzed. Unidimensionality of the scale was tested by confirmatory factor analysis (CFA), principle component analysis (PCA) and local dependency (LD) statistic. Graded response model was fitted to the data. Contribution of each item to the scale was assessed by item information function (IIF). Reliability of the scale was assessed by test information function (TIF). Differential item functioning (DIF) across gender was identified by Wald test and expected score functions.ResultsBoth CPQ11–14 RSF:8 and ISF:8 did not deviate much from the unidimensionality assumption. Results from CFA indicated acceptable fit of the one-factor model. PCA indicated that the first principle component explained >30xa0% of the total variation with high factor loadings for both RSF:8 and ISF:8. Almost all LD statistic <10 indicated the absence of local dependency. Flat and low IIFs were observed in the oral symptoms items suggesting little contribution of information to the scale and item removal caused little practical impact. Comparing the TIFs, RSF:8 showed slightly better information than ISF:8. In addition to oral symptoms items, the item “Concerned with what other people think” demonstrated a uniform DIF (pu2009<u20090.001). The expected score functions were not much different between boys and girls.ConclusionsItems related to oral symptoms were not informative to OHRQoL and deletion of these items is suggested. The impact of DIF across gender on the overall score was minimal. CPQ11–14 RSF:8 performed slightly better than ISF:8 in measurement precision. The 6-item short forms suggested by IRT validation should be further investigated to ensure their robustness, responsiveness and discriminative performance.

Early Childhood Caries: A Literature Review

Early Childhood Caries (ECC) is defi ned as the presence of one or more decayed tooth surfaces in any primary tooth in children 71 months of age or younger. ECC is the most common chronic illness among children and adolescents. Studies have found caries prevalence among preschool children varies greatly in different countries, ranging from 17 to 94%. However, in most of the studies; over 90% of decayed teeth were left untreated. Caries progression can lead to pain and reduced ability to chew and eat, which may also lead to iron defi ciency due to malnutrition. Reduction of quality of life for children with ECC, resulting from disturbed sleeping and concentration problems, has been reported. Children with severe caries may experience reduced weight and delayed growth. This paper provides an updated literature review of ECC. The aetiology, clinical features, caries prevalence in recent literature, consequences of caries infection and management of ECC are discussed.