Dental cavities is one of the most common disease processes across all populations throughout the universe and a cardinal factor in dental hurting and tooth loss. Caries is a procedure that can happen on any tooth surface in the oral cavity where alveolar consonant plaque is able to develop over clip. Bing a biofilm, plaque contains many different microorganisms that work together and are continually active. Some of these bacteriums are able to ferment soluble saccharides to bring forth acids, ensuing in a bead in sourness below pH 5 and hence doing demineralization of the enamel surface. Acid is neutralized by spit and the demineralization procedure halted, as the pH rises, mineral may be regained and remineralisation can happen. If the cumulative consequence of these procedures is a net loss in mineral, a carious lesion will be observed. The carious procedure is hence natural and can non be prevented nevertheless with suited intercession, the patterned advance into a seeable lesion can be avoided1.
The bar of cavities is considered more cost-efficient than intervention and is hence considered a priority2. Fluoride varnishes since the 1960 's have been clinically utilized for this reason17,18. Application of concentrated fluoride varnishes to tooth surfaces consequences in the formation of Ca fluoride. As the sourness of the environment additions, a greater sum of enamel disintegration occurs and hence an copiousness of ionic Ca allows for a considerable sum of Ca fluoride formation. Significant precipitation of spherical globules of Ca fluoride in dental plaque and unaccessible countries is of great benefit leting for important remineralisation due to the high concentration of free ionic Ca available3. Fluoride besides has a direct consequence on bacterial metamorphosis ( see appendix 4, table 1 for details16 ) .
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Of the three surveies reviewed, one was carried out in Sweden4, one in Florida5 and one in San Francisco6. In these trials,1375 participants were studied runing from ?1.8 to 16 old ages old and followed for periods between 9 months and 3 old ages. Each survey had a specific purposes, one focused on a school based fluoride varnish programme and the patterned advance and incidence of approximal cavities from high, medium and low socio-economic backgrounds4. Another concerned the efficaciousness of fluoride varnish in add-on to reding in the bar of early childhood caries6, whilst the concluding survey evaluated the consequence of fluoride varnish on enamel cavities patterned advance in the primary dentition5. The chief features of each survey and their consequences are displayed in Appendices 14, 25 and 36.
Randomization was used to delegate participants into each of the groups in all tests and one study6 outlined the allotment technique used. Two surveies were individual blind4,5 where the tooth doctor was incognizant of the group allotments and one was conducted as a dual blind trial6.
All surveies used Duraphat ( 5 % Sodium Fluoride 22,600 F-ppm ) with two studies5,6 using varnish to all tooth surfaces and the 3rd study4 using varnish merely to approximal surfaces from the distal surface of the eyetooths to the mesial surface of the 2nd grinders. Two surveies stated the sum of fluoride varnish to be used ; 0.1ml per arch6 and ?0.3ml in total4.
Examination techniques differed amongst the three selected surveies. One conducted a ocular scrutiny three times6, another conducted four overall bitewing radiogram at baseline and after the trial4. The 3rd conducted both radiographic bitewings and a ocular scrutiny besides at baseline and following the test, explicitly discoursing the method6.
All experiments experienced a loss of participants to some grade. Weintraub et al.6 concluded 67 % of participants enrolled at baseline saw the survey through, the test conducted by Autio-Gold et al.5 retained 81 % of initial participants. In the concluding experiment by Sk & A ; ouml ; ld et al.4, 89 % of topics completed the test.
Ultimately, all surveies agreed fluoride varnish is of significance in forestalling caries4,5,6 and may be effectual in change by reversaling cavity and crevice enamel lesions5. Findingss were assessed in footings of statistical significance and all three4,5,6 gave P values. Differences in measuring lesions clinically can be seen. Sk & A ; ouml ; l et al.4 used a self-devised numbered marking system to find cavities incidence and patterned advance of carious lesions. Weintraub et al.6 used the NIDCR diagnostic standards for dental caries7 for the appraisal of cavitated, decayed and filled surfaces on primary dentitions and auxiliary criteria8 to name pre-cavitated lesions. Finally Autio-gold et al.5 utilised a marking system9 which differentiates between active and inactive enamel carious lesions.
Although all surveies statistically support the usage of fluoride varnish in the bar of cavities, the methodological analysis of each demand to be considered before any decisions can be drawn. Double blind randomized control tests are considered the 'gold criterion ' in footings of survey design10 and minimise prejudice. In all of these tests, the tooth doctors were incognizant of patient allocated groups nevertheless in two4,5, the participants were cognizant. This could hold led to bias in those surveies as cognizing they were portion of a test with regular follow up periods, patients may hold been more self-aware with respect to their unwritten wellness and hence take more preventive steps compared to groups with fewer visits. Overall this consequence may give the feeling that a more frequent application of varnish reduces cavities incidence.
Sample size demands to be taken into history as a larger cohort will give a more accurate representation of the population, doing Sk & A ; ouml ; l et al.4 the most representative of the three tests. Gender was reasonably every bit distributed in both varnish and hazard groups. This is of significance as it has been shown that females are by and large more compliant than males11 and therefore are more likely to brush on a regular basis, maintaining to the survey design. Bias in this illustration is hence reduced as females are every bit distributed across all groups. Weintraub6 and Autio-Gold5 did non advert gender distribution and hence lend themselves to this prejudice.
When sing the clip period in which tests are conducted, a greater clip graduated table allows for a more comprehensive result. Potential side effects of fluoride varnish are more likely to go evident and its anti cavities consequence can be reviewed for any possible alterations as there may be a critical period for which it has consequence. Again, Sk & A ; ouml ; l et al.4 conducted the longest test at 3 old ages and hence in footings of clip period, have the most accurate consequences for effects of fluoride and its side effects, of which they found none. Weintraub et al.6 besides used a sensible clip period and would demo any side-effects or critical periods for fluoride applications, merely one kid in the group having fluoride four times a twelvemonth developed an ulcer on their cheek which had resolved at the following followup. There is no grounds to back up unwritten ulcerations as a consequence of fluoride varnish application. The test conducted Autio-Gold5 was over a shorter period and hence compared to Weintraub6 and Sk & A ; ouml ; l4, can non be as conclusive in critical periods of application and side effects.
Follow up periods are of relevancy as changing frequences of application can be assessed for effectivity. Sk & A ; ouml ; l et al.4 utilised the greatest figure of groups with the most differing frequences to set up the most effectual intervals. The method in which fluoride varnish was applied varied and one specific survey, Autio-Gold5, failed to stipulate whether application on all tooth surfaces at the 2nd follow up occurred, as at the baseline. Besides the sum of fluoride varnish applied is non stated as in the two other studies4,6. Therefore the survey can potentially be classified as inconsistent and cogency of the consequences questionable. Application of the varnish was conducted in similar ways across all three tests nevertheless Weintraub et al.6 used ?66 % of the fluoride varnish than Sk & A ; ouml ; l et al.4 and it must be considered that a higher dose of fluoride may hold a greater preventive consequence.
The locations in which the surveies took topographic point differ. Sk & A ; ouml ; l et al.4 conducted their probe in Sweden where H2O is fluoridated. Socio-economic position is associated with unwritten health12 and in this survey, the low hazard group had a high socio-economic position. The extra factor nevertheless, is that the location of this group is besides in an country of H2O fluoridization ten times higher than that of the medium or low hazard groups. It has been shown that fluoridization reduces cavities incidence13 intending these participants technically received an increased dose and therefore may hold influenced the consequences to demo a decreased effectivity of fluoride varnish. In the other two studies5,6 this variable was controlled and Weintraub et al.6 ensured participants resided in the country for at least 2 old ages.
Age of participants is of importance as striplings in the Sk & A ; ouml ; l et al.4 survey are responsible for their ain unwritten hygiene and it has been shown that 25 % of 14-year-olds do non on a regular basis brush their teeth14,15. Consequences can hence be influenced in this test. If ?25 % participants did non brush on a regular basis, theoretically it would do increased cavities incidence in these people compared to the other 75 % of the cohort and finally give the feeling fluoride varnish has a lesser consequence than in world. Autio-Gold5 and Weintraub6 used primary5 and pre-school6 kids where parents and defenders are more likely to conform to the survey design and better the cogency of the consequences.
Consequences were based on the findings of the testers therefore their determinations are important. Autio-Gold5 and Weintraub6 both calibrated testers nevertheless Sk & A ; ouml ; l et al.4 did non advert any dependability apart from re-examining radiogram after 2 months, the consequences of which, are non published. There is hence a possibility of inaccuracy in cavities diagnosing at each follow up, which would give either a greater or lesser perceived fluoride consequence depending on tester tolerance. Caries diagnosing methods vary, ideally a radiographic and ocular scrutiny should be conducted as white topographic point lesions and early cavities can non be seen radiographically, the attack taken by Autio-Gold et al.5. Weintraub et al.6 used merely ocular scrutinies and hence, although improbable, potentially leting for non-cavitated lesions to be missed. Sk & A ; ouml ; l et al.4 took merely radiographs nevertheless this was appropriate as approximal cavities can be merely be seen in this manner.
Deviations in protocol can be seen in two surveies. In Sk & A ; ouml ; l et Al. 's4 test, all groups received an extra application of fluoride every one-year visit including the control group. Realistically the control group hence received intercession and perchance affected the consequences. Weintraub et al.6 experienced a more terrible divergence. For 10 months, participants received a placebo varnish alternatively of the active merchandise and merely one kid received all four planned applications. Besides 21 applications could non be confirmed as active and were assumed placebo. This may hold given the feeling of a greater good consequence of fluoride varnish if the placebo was active. Any long term positive or negative effects can therefore non be concluded with every bit much assurance as the other two trials4,5 as there was a interruption in the application of active merchandise.
A Cochrane systematic review19 determined that on norm, fluoride varnish reduced cavities in the deciduous teething by 33 % and by 46 % in the lasting teething.
In decision, holding considered the grounds base for the usage of fluoride varnish and evaluated the advantages and disadvantages of all mentioned surveies and their restrictions, fluoride varnish is an effectual method in commanding cavities incidence and patterned advance.
Fluoride varnish should be indicated in all kids and striplings. Adults with a high cavities hazard should besides be considered, such as those with particular demands, dry mouth or active carious lesions. Children and striplings should have application biannually and grownups with carious lesions or particular demands should hold varnish applied between two and four times yearly. No common or serious inauspicious effects have been reported in any surveies. As a safeguard fluoride varnish is contraindicated in terrible asthmatics, ulcerative gingivitis and stomatitis. Besides allergy to seal components is an obvious contraindication.
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Sk & A ; ouml ; ld 20054:
Randomised control test, individual blind to dentist. 11 % bead out after 3 old ages. Reasons for bead out include traveling off from country and non go toing all Sessionss. Overall 96 losingss.
758 participants analysed at 3 old ages ( concluding scrutiny )
Average age at get downing: 13 old ages
Exposure to other fluoride: H2O, toothpaste, varnish at annually check-up
Year survey began: 1998
Fluoride varnish Duraphat ( 22,600 ppm F- ) ( 3 groups ) vs. control group:
Group 1: F- varnish 2x yearly at 6 month intervals
Group 2: F- varnish 3x yearly within one hebdomad
Group 3: F- varnish 8x yearly with 1 month intervals
Control group: No intercession
Teeth cleaned with toothbrush without toothpaste and interproximally cleaned utilizing dental floss
Applied ?0.3ml with syringe on all approximal surfaces from distal of eyetooth to mesial of 2nd grinder.
Prevented fraction in per centum in the different cavities risk countries and all countries together ( Table 3 ) 4
Participants randomised ( n=854 )
All groups including control exposed to fluoride at one-year cheque up
Figures and tabular arraies demoing consequences from Sk & A ; ouml ; ld et al.4
Randomised control test, individual blind to dentist. 19 % bead out rate after 9 months. Due to backdown of school programme, traveling from country, refusal to go on and six topics necessitating renewing intervention instantly after survey began. Overall 35 losingss.
148 participants analysed at 9 months ( concluding scrutiny )
Average age at get downing: 3 to 5 old ages
Exposure to other fluoride: H2O
Year survey began: Not stated
Location: Florida, USA
Fluoride varnish Duraphat ( 22,600 ppm F- )
Varnish group: 2x over 9 months, one time at baseline and one time after 4 months
Control group: No intercession
In dental clinic, dried dentition with tight air and applied varnish with little coppice to all tooth surfaces. In school dentitions dried with unfertile cotton sponges and varnish applied to all tooth surfaces with coppice.
Change in carious activity between varnish and control group
No alteration ( i.e. still active )
Inactive lesions ( i.e. no longer active )
Participants randomised ( n=183 )
Does non province whether or non varnish was applied to all surfaces during the 2nd visit in varnish group. Besides how much varnish applied in both visits.
Figures and tabular arraies demoing consequences from Autio-Gold et al.5:
Randomised controlled dual blind test. 33 % bead out rate after 2 old ages. 51 discontinued from survey due to cavities.
202 participants analysed at 2 old ages ( concluding scrutiny )
Average age at get downing: 1.8 old ages
Exposure to other fluoride: H2O
Year survey began: 2002
Location: San Francisco, USA
Fluoride varnish Duraphat ( 22,600 ppm F- )
Group 1: F- varnish 4x over 2 old ages ( baseline, 6, 12 and 18 months )
Group 2: F- varnish 2x over 2 old ages ( baseline and 12 months )
Control group: Parental guidance
All groups received parental guidance.
0.1ml applied per arch. Dried with gauze and varnish brushed onto all surfaces of all dentitions. For control group, teeth dried and gauze folded dry surface brushed onto dentitions and therefore health professionals unaware of groups.
Cavities activity across the three groups:
Participants randomised utilizing computing machine generated random assignment ( n=384 ) .
75 % kids intended to have two applications merely received one ; 15 % received two.
49 % kids intended to have four applications merely received two.
One kid received four applications.
For five hebdomads, 21 varnish applications could non be confirmed as active - assumed placebo.
Figures and tabular arraies demoing consequences from Weintraub et al.6:
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