Accepted Manuscript

Letter to the Editor

Marília Afonso Rabelo Buzalaf

PII: S1532-3382(14)00091-8

DOI: 10.1016/j.jebdp.2014.04.027

Reference: YMED 978

To appear in: The Journal of Evidence-Based Dental Practice

Please cite this article as: Buzalaf MAR, Letter to the Editor, The Journal of Evidence-Based DentalPractice (2014), doi: 10.1016/j.jebdp.2014.04.027.

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We would like to thank Professor Santos and colleagues for providing us the opportunity to discuss the effect of low fluoride toothpaste on caries prevention in deciduous teeth and on dental fluorosis risk. We disagree with the conclusion of their paper1 in respect to the risk of dental fluorosis only. The authors presented the following conclusion: “We found no evidence to support the use of low F toothpastes by preschoolers as they increased the risk of caries in the primary dentition and did not decrease the risk of aesthetically objectionable fluorosis in upper permanent anterior teeth.” This conclusion (underlined sentence) was not based on the statistical analysis done by the authors, where RR value was 0.32 (68% less chance in developing aesthetically fluorosis for children using low fluoride toothpaste compared to those using standard fluoride toothpaste). However, the RR value was calculated from the data of two studies with a high level of significant inhomogeneity. Based on this, any affirmation on this subject is invalid. Insufficient clinical data are available about the effect of low fluoride toothpaste compared to standard fluoride toothpaste on dental fluorosis risk in young children. Therefore the authors could lead readers to think that low fluoride toothpaste cannot decrease dental fluorosis risk. This topic deserves fuller investigation. With respect to the useful information provided by Santos and colleagues, we would like to comment following their sequence: 1. We agree with this affirmation, which was not a point of question in the critical analysis of the paper. 2. The authors should be careful when extrapolating the results with respect to dental fluorosis risk. Both cited studies presented highly discrepant results: Holt et al2 found a RR of 0.8 when comparing low to standard fluoride toothpaste, whereas Tavener et al3 showed a RR of 0.09. These different values explain the high level of inhomogeneity. Furthermore, the baseline age of the patients and the time of follow-up were quite different between the studies. Finally, the studies were done in non-fluoridated or non-optimally fluoridated areas. All these limitations should have been considered in the interpretation of the data and especially in the translation for clinical practice. The lack of trustworthy data impairs any conclusion about the relationship between the use of low fluoride toothpaste and the risk of dental fluorosis. 3. We agree that the prevalence of TF ≥ 3 is very low4-6 and the use of fluoride toothpaste is more related to the occurrence of questionable or very mild fluorosis (56% TF1).3 Tavener et al3 found significantly more enamel defects in children (% of teeth) using standard compared to low fluoride toothpastes when TF ≥ 1 or TF ≥ 2 was considered in the statistical analysis. When they analyzed TF ≥ 3, no differences between toothpastes were found. If we consider TF ≥ 2, for example, in the meta-analysis (% of children), the RR would be 0.61 (low 26/490 and standard 41/469). This scenario may explain why most of the available evidence focuses on very mild and mild fluorosis.7 Accordingly, we are concerned about how relevant it is to consider TF ≥ 3 in the analysis of the relationship between the use of fluoride toothpaste and the risk of dental fluorosis. 4. We agree with these colleagues that the analysis of caries in dentin is an important clinical step to check the impact of the measurement. The conclusion of the authors with respect to dental caries increment is in accordance with the meta-analysis. The caries risk was 13% higher for children using low compared to those using the standard fluoride toothpaste. The clinical impact of this finding in terms of treatment need was highly dependent on the caries risk. Taking into account all findings, there is an urgent need for longitudinal clinical trials considering the caries

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risk (activity) of the patients in the caries lesion assessment together with the analysis of dental fluorosis incidence related to the use of low fluoride toothpaste. Some insights into this aspect were given in the clinical trial of Lima et al8 and de Almeida Baldini Cardoso et al9, where enamel caries lesions were assessed. According to these studies,8,9 the child’s caries activity may be taken into account to recommend a low fluoride dentifrice. The conclusion of the authors1 was distinct from that reported in the paper by Wong et al7 (underlined sentence), who stated: “Thus, considering the results from the two reviews as supplementary to each other, and balancing both benefits and risks, the evidence indicates that, for preventing caries in children and adolescents, toothpastes of at least 1000 ppm fluoride should be used. From 1000 ppm fluoride, there is a dose-response relationship for caries prevention that should be taken into account when advising older children at high risk for caries. For very young children, consideration should be given, when brushing with concentrations greater than 1000 ppm fluoride, to their risk of developing mild fluorosis; a risk-benefit decision needs to be discussed with parents/guardians.” On the other hand, Walsh et al10 supported the use of 1000 ppm F toothpaste for young children, as stated by Santos et al.1

However, the former authors also commented that “The decision of what fluoride levels to use for children under 6 years should be balanced with the risk of fluorosis.” Therefore Wong et al7 and Walsh et al10 opened some possibilities for the use of fluoridated toothpaste in young children based on the risk-benefit decision. Furthermore, Wong et al7 advised that the dentist should discuss with parents and collaboratively come to a decision, whereas in the paper of Santos et al,1 nothing is mentioned about considering private and public treatment. Finally, we thank the authors for making us aware of the mistakes in the references. We have asked the Journal to make the appropriate corrections. References 1. Santos AP, Oliveira BH, Nadanovsky P. Effects of low and standard fluoride

toothpastes on caries and fluorosis: systematic review and meta-analysis. Caries Res 2013;47(5):382-90.

2. Holt RD, Morris CE, Winter GB, Downer MC. Enamel opacities and dental caries in children who used a low fluoride toothpaste between 2 and 5 years of age. Int Dent J 1994;44(4):331-41.

3. Tavener JA, Davies GM, Davies RM, Ellwood RP. The prevalence and severity of fluorosis in children who received toothpaste containing either 440 or 1,450 ppm F from the age of 12 months in deprived and less deprived communities. Caries Res 2006;40(1):66-72.

4. da Cunha LF, Tomita NE. Dental fluorosis in Brazil: a systematic review from 1993 to 2004. Cad Saude Publica 2006;22(9):1809-16.

5. Beltran-Aguilar ED, Barker L, Dye BA. Prevalence and severity of dental fluorosis in the United States, 1999-2004. NCHS Data Brief 2010 Nov(53):1-8.

6. Ministério da Saúde. Projeto SB Brasil 2010: Pesquisa Nacional de Saúde Bucal - Resultados principais. Brasília, DF. 2011.

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7. Wong MC, Glenny AM, Tsang BW, Lo EC, Worthington HV, Marinho VC. Topical fluoride as a cause of dental fluorosis in children. Cochrane Database Syst Rev 2010(1):CD007693.

8. Lima TJ, Ribeiro CC, Tenuta LM, Cury JA. Low-fluoride dentifrice and caries lesion control in children with different caries experience: a randomized clinical trial. Caries Res 2008;42(1):46-50.

9. de Almeida Baldini Cardoso C, Mangueira DF, Olympio KP, Magalhães AC, Rios D, Honório HM, Vilhena FV, Sampaio FC, Buzalaf MA. The effect of pH and fluoride concentration of liquid dentifrices on caries progression. Clin Oral Invest 2013 Jul 20.

10. Walsh T, Worthington HV, Glenny AM, Appelbe P, Marinho VC, Shi X. Fluoride toothpastes of different concentrations for preventing dental caries in children and adolescents. Cochrane Database Syst Rev 2010(1):CD007868.