Fluorides for preventing early tooth decay during fixed brace treatment

Wearing a fixed brace makes it harder for people to keep their teeth clean and may also cause pain. Pain can make it more difficult for people to brush their teeth. This can lead to a build-up of dental plaque around the brackets that attach the fixed brace to the teeth. If the plaque stays on the tooth for long enough, it will cause early tooth decay, which looks like white or brown marks (demineralised lesions, also known as white spot lesions). People often wear braces for 18 months or longer and if the decay is left to progress, it can cause holes, which are sometimes bad enough to need fillings to be done in the teeth.

Fluoride helps the tooth to heal, reducing tooth decay in people who are at risk of developing it. People receiving fixed brace treatment may be given different forms of fluoride treatment. It is important to think about how the fluoride gets to the teeth. Does the fluoride need to be placed by a dentist or dental nurse, or can people having treatment with braces apply the fluoride to their own teeth? Continue reading

Which strength of fluoride in toothpaste is most effective?

Tooth decay (caries) is a widespread disease, affecting billions of people worldwide. Fluoride has long been used to prevent decay, through a variety of different methods including toothpaste, water, milk, mouthrinses, tooth gels and varnish. Regular toothbrushing is recommended to prevent decay and other oral diseases, and toothbrushing for 2 minutes twice daily with a fluoride toothpaste is generally recommended. The typical strength of regular or family toothpaste is around 1000 to 1500 parts per million (ppm) fluoride, but many other strengths are available worldwide. There is no minimum fluoride concentration, but the maximum permissible fluoride concentration for a toothpaste varies according to age and country. Higher concentrations are rarely available over the counter, and are classed as a prescription‐only medicine. Stronger fluoride toothpaste may offer greater protection against decay but also increases the risk of fluorosis (enamel defects) in developing teeth. This is an update of the Cochrane Review first published in 2010. Continue reading

Slowly does it: no evidence that slow-release fluoride devices are effective

Tooth decay is not distributed evenly among the population, with certain groups being at greater risk of developing tooth decay than others. For example, research in Scotland has shown that 50% of tooth decay occurs in 11% of 5-year-old children and only 6% of 14-year-old children. In light of this uneven distribution, it is often suggested that these small percentages of children may be offered targeted-caries preventive measures to great potential effect, in a cost effective manner. One such preventive measure is the use of slow-release fluoride devices (e.g. slow-dissolving fluoride-releasing glass beads). Continue reading

Fluoride gel reduces tooth decay in children


Gel is normally applied using dental trays

Tooth decay affects 60% to 90% of children. Levels of tooth decay vary between and within countries, but it is generally true that children in lower socioeconomic groups (measured by income, education and employment) have more tooth decay. Over time, untreated tooth decay causes progressive destruction of the tops of teeth (crowns); this is often accompanied by severe pain. Repairing and replacing decayed teeth is extremely costly in terms of time and money and is a major drain on the resources of healthcare systems. The prevention of tooth decay in children and adolescents is regarded as a priority for dental services and is considered more cost-effective than its treatment. The use of fluoride, a mineral that prevents tooth decay, is widespread. As well as occurring naturally, fluoride is added to the water supply in some areas, and it is used in most toothpastes and in other products that are available to varying degrees worldwide. As an extra preventive measure there are other ways of applying fluoride directly to teeth, such as mouthrinses, lozenges, varnishes and gels. Fluoride gel is usually applied by a dental professional, or self applied under supervision (depending on the age of the child), from once a year to several times a year. The gel is usually placed in a tray that the child or young person must keep in their mouth and bite into for about four minutes. It is not uncommon for young people to accidentally swallow some of the gel; feelings of sickness, vomiting, headache and stomach pain have been reported when too much is swallowed. Due to this risk of toxicity, fluoride gel treatment is not generally recommended for children younger than six years old. Continue reading

Demineralized white lesions – what’s the best way to prevent them during orthodontic treatment?


Adjusting the braces… Should orthodontists be applying fluoride varnish at every visit?

The orthodontists working with the Cochrane Oral Health Group have been busy over the last few months. Another brand new review update has been published in the Cochrane Library!

Ugly white marks (demineralised white lesions) sometimes appear on the teeth during treatment with braces or other orthodontic devices. These are caused by early tooth decay and usually occur with fixed (glued on) braces. Fluoride in toothpaste helps to prevent dental decay, but is there evidence that giving people having orthodontic treatment extra fluoride will prevent these lesions? This review looks at the evidence. Continue reading

Updated systematic reviews from the Oral Health Group


c. Malcolm Koo under the Creative Commons Share-Alike License

Issue 7, 2013 of the Cochrane Library has been published, and features two new updates from the Cochrane Oral Health Group. Follow the links to read more!

New update: Interventions for replacing missing teeth: antibiotics at dental implant placement to prevent complications
By Marco Esposito, Maria Gabriella Grusovin and Helen V Worthington

This updated review looks at whether antibiotics should be given prior to dental implants to prevent infections which can threaten implant stability. Six randomized controlled trials were included, with 1,162 participants. All six of these trials compared the use of antibiotics to prevent infection (failures and complications) with no treatment or treatment with a placebo . The antibiotic used in all the trials was amoxicillin; doses and timing of doses varied, although most used a single dose taken just before the implant was placed. One of the trials, with 100 participants, also looked at different doses of amoxicillin taken at different times. It appears that the oral administration of two grams of amoxicillin one hour before placement of dental implants is effective in reducing implant failures. More specifically, giving antibiotics to 25 people will avoid one person experiencing early implant losses. It is still unclear whether postoperative antibiotics are beneficial, or which antibiotics work best.

New update: Fluoride varnishes for preventing dental caries in children and adolescents
by Valeria CC Marinho, Helen V Worthington, Tanya Walsh and Jan E Clarkson

This is an update of a review which looks at whether fluoride varnish is effective in preventing tooth decay in children. 22 randomized controlled trials were included, with a total of 12,455 participants. 13 of the trials looked at older children who have permanent (adult) teeth, and fluoride varnish was found to reduce decayed or missing teeth by 43%. Children who still have their baby or milk teeth were covered in 10 of the trials. For this group of children, fluoride varnish reduced decayed or missing teeth by 37%. The evidence produced has been found to be of moderate quality due to issues with trial designs.

Other highlights of the Cochrane Library, Issue 7 include:

New Oral Health Group Podcast


c Liam Dunn, published under Creative Commons licence

Did you know? There are now a range of Cochrane podcasts available on the Cochrane Library.

The latest Oral Health Group podcast is by the University of Manchester’s Lucy O’Malley, who gives the lowdown on her review: Primary school interventions for preventing caries. Follow the link to listen in and hear the findings!

Other available Oral Health Group podcasts include:

Follow the links to read the Cochrane Summary, and then click “Podcast” on the bottom right of the page to listen.

Review of the Month: a coat of varnish?


c. Indian Health Service

Tooth decay or dental caries is a worldwide health problem, up to 90% of children are affected. Fluoride is a mineral which prevents tooth decay. It can be applied directly to children’s teeth in the form of a varnish, by a dental professional.  How effective is it as a prevention measure? Our Review of the Month for July is an update – hot off the press!

What was the research?

A systematic review of the evidence to find out how effective fluoride varnish is for prevention of tooth decay in children and adolescents. In all cases, the varnish was compared to a placebo, i.e. a treatment without fluoride.

Who conducted the research?

The research was conducted by a team led by Valeria Marinho from Barts and the London School of Medicine and Dentistry in the UK, on behalf of the Cochrane Oral Health Group. Helen Worthington, Tanya Walsh and Jan Clarkson were also on the team.

What evidence was included in the review?

Data was extracted from 22 randomised controlled trials. A total of 12,455 children participated in the trials, and were randomly assigned to treatment with fluoride varnish, or placebo.

What did the evidence say?

The evidence says that fluoride varnish can be used to prevent tooth decay. 13 of the trials looked at older children who have permanent (adult) teeth, and fluoride varnish was found to reduce decayed or missing teeth by 43%. Children who still have their baby or milk teeth were covered in 10 of the trials. For this group of children, fluoride varnish reduced decayed or missing teeth by 37%.

There was little information in the trials on whether fluoride varnish has significant side effects.

How good was the evidence?

The evidence is of moderate quality. None of the 22 included trials were assessed as having a low risk of bias. 68% of the trials were at high risk of bias. This is due to several factors, including the high drop out rate of the participants, and poor quality reporting.

What are the implications for dentists and the general public?

The review found that the application of fluoride varnish 2 to 4 times per years, either in permanent or baby teeth, can reduce tooth decay in children. This applies in populations with different levels of risk and exposure to other sources of fluoride (such as fluoride in the water supply).

What should researchers look at in the future?

Despite the large number of trials on fluoride varnish, there are not enough high quality studies at low risk of bias. Well designed studies are needed. Future studies should also look at the potential side effects of fluoride varnish (for example, allergic reactions) and should look at fluoride varnish used in combination with other preventative measures.


Marinho VCC, Worthington HV, Walsh T, Clarkson JE. Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2013, Issue 7. Art.No.: CD002279. DOI: 10.1002/14651858.CD002279.pub2.

New titles registered at the Cochrane Oral Health Group

Two new titles have been recently registered with the Cochrane Oral Health Group:

Triclosan containing toothpastes for gingival health
This review will be undertaken by a team from Manchester, UK and Dundee, UK. It will consider the effectiveness of toothpastes containing triclosan for the management of gingivitis.

pregnant-woman-brushing-teeth_Naijapals[dot]comFluoride supplementation in pregnancy for improving outcomes
This review will consider whether administering pre-natal fluoride will prevent dental caries (tooth decay) in children. It will be undertaken by a team from Japan.

We look forward to publishing both protocols in due course.

The new edition of the Cochrane Library for July 2012 is out today!

The July 2012 edition of the Cochrane Library has been published and features two new protocols from the Cochrane Oral Health Group:

Chlorhexidine versus topical fluoride treatment for the prevention and management of dental caries in children and adolescents
Joerg Eberhard, Tobias Sandmann, Valeria CC Marinho, Henrik Dommisch, Sören Jepsen, Meike Stiesch, Werner Geurtsen

 A protocol for a new review which will consider how topical chlorhexidine compares with topical fluoride on all tooth surfaces in children and adolescents in the prevention and management of tooth decay. The treatment could be a varnish, toothpaste, mouth rinse, gel, spray or chewing gum. The review and results will be published soon!

Direct versus indirect bonding for bracket placement in orthodontic patients
Wenya Huang, Fan Jian, Wenli Lai, Wen Li, Declan T Millett, Grant T McIntyre, Zhihe Zhao, Yan Wang, Zongdao Shi, Taixiang Wu, Guan J Liu, Joy Hickman, Amit Arora

This protocol sets out the methodology for a new review on bonding in placing brackets in orthodontic treatment. It will consider whether directly bonding braces to the teeth is more effective than indirect bonding,  i.e. placing brackets on a plaster model of the patient’s teeth first for adjustment and then transferring to the mouth via a tray.

Other highlights of the Cochrane Library, Issue 7, 2012 include: