ORAL HEALTH

Health Evidence Bulletins - Wales
Team Leader: Mr Tony Glenn

Date of completion: 5/2/1998

The contents of this bulletin are likely to be valid for approximately one year, by which time significantly new research evidence may become available


1. Tooth Decay

(Users are advised to consult the supporting evidence for a consideration of all the implications of a recommendation)

The Statements The Evidence
1a. An optimal concentration of fluoride ions in public water supplies protects teeth against decay, leading to a reduction in dental caries by up to 50% in deciduous and permanent teeth and in the adult dentition. Some water fluoridation schemes have been running for more than 50 years. Despite extensive study, no adverse effects to the human body have been demonstratedi,ii,iii.

(Health gain notation - 1 "beneficial")

i. Ripa LW. A half-century of community water fluoridation in the united states: review and commentary - Journal of Public Health Dentistry 1993; 53 (1): 17-44
(Type III evidence - well designed non-random trial);
ii. Subcommittee on Health Effects of Ingested Fluoride. Health effects of ingested fluoride. Washington DC: National Academy Press, 1993
(Type IV evidence - observational studies);
iii. Community Dental Health September 1996; Volume 13, Supplement 2.
(Type IV evidence - observational studies)
1b. The use of fluoride supplementation in caries prevention would seem to be effective but compliance can be problematic. A reduction in dental caries by up to 50% is observed in individuals at risk of developing dental caries, who can be persuaded to complyi.
(Health gain notation - 2 "likely to be beneficial")
Dosage for young children should aim to reduce the risk of fluorosis due to this source of fluorideii
i. Stephen KW. Systemic fluorides: Drops and tablets. Caries Research 1993; 27(suppl.1):9-15
(Type V evidence - expert opinion)
ii. Riordan PJ, Dipedod MPH.  The place of fluoride supplements in caries prevention today.  Australian Dental Journal 1996; 41(5): 335-342
(Type V evidence - expert opinion)
1c. Plaque control using fluoride toothpaste is effective in the prevention of tooth decay. There are long term clinically significant reductions in dental caries showing a dose - response relationship i,ii,iii,iv.

(Health gain notation - 1 "beneficial")

i. Stephen KW. Dentifrices: recent clinical findings and implications for use. International Dental Journal 1993; 43 (6 suppl.1): 549-553
(Type V evidence - expert opinion);
ii. Stephen KW. Fluoride toothpastes, rinses and tablets. Advances in Dental Research 1994:8 (2): 185-189
(Type V evidence - expert opinion);
iii. Johnson MF. Comparative efficacy of NaF and SMFP dentifrices in caries prevention: a meta-analytic overview. Caries Research 1993; 27: 328-336
(Type I evidence - systematic review);
iv. Stookey GK, DePada PF, Featherstone JDB et al. A Critical review of the relative anticaries efficacy of sodium fluoride and sodium monofluorophosphate dentifrices. Caries Research 1993; 27: 337-360
(Type I evidence - systematic review)

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1d. Sodium fluoride is recommended for use as the active system in fluoridated dentifrices whenever practically feasible. However, the formulation should include highly compatible abrasive systems, which must be demonstrated by critical evaluation of ionic fluoride within formulations for stability, availability and bioavailability. Over a 2-3 year period, caries reduction by sodium fluoride was 6.4% higher than by sodium monofluorophosphate. The average difference for that period in caries increment was 0.28 surfaces (confidence interval, 0.10 - 0.46) i,ii.
(Health gain notation - 1 "beneficial")
i. Johnson MF. Comparative efficacy of NaF and SMFP dentifrices in caries prevention: a meta-analytic overview. Caries Research 1993; 27: 328-336
(Type I evidence - meta-analysis);
ii. Stookey GK, DePada PF, Featherstone JDB et al. A critical review of the relative anticaries efficacy of sodium fluoride and sodium monofluorophosphate dentifrices. Caries Research 1993; 27: 337-360
(Type I evidence - systematic review)
1e. Fluoride varnishes reduce dental cariesi and are particularly recommended for special needs groupsii.

(Health gain notation - 1 "beneficial")

i. Helfeustein U, Steiner M. Fluoride varnishes (Duraphat): a meta-analysis. Community Dentistry and Oral Epidemiology 1994; 22: 1-5
(Type I evidence - meta-analysis);
ii. Oral Health. Protocol for Investment in Health Gain. Welsh Health Planning Forum. Cardiff: Welsh Office NHS Directorate, November 1992
(Type V evidence - expert opinion)
1f. Fluoride rinses reduce dental cariesi and are recommended for special needs groupsii.

(Health gain notation - 1 "beneficial" )

i. Stephen KW. Fluoride toothpastes, rinses and tablets. Advances in Dental Research 1994:8 (2): 185-189
(Type V evidence - expert opinion);
ii. Oral Health. Protocol for Investment in Health Gain. Welsh Health Planning Forum. Cardiff: Welsh Office NHS Directorate, November 1992
(Type V evidence - expert opinion);
1g. A reduction in sugar in the diet is associated with reduced levels of tooth decay i.

(Health gain notation - 1 "beneficial")

i. Rugg-Gunn AJ. Nutrition and dental health. Chapter. 6. Dental caries - the role of dietary sugars. Oxford: Oxford University Press, 1993 pp. 113-193
(Type III evidence - well designed trials)

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1h. To reduce dental caries, bottle feeding should be discouraged, especially from the age of one yeari.

(Health gain notation - 1 "beneficial")

i. Committee on Medical Aspects of food Policy. Weaning and the weaning diet. Report of the Working Group on the weaning diet of the Committee on Medical Aspects of Food Policy. Summary. Cardiff: Welsh Office, March 1995.
(Type V evidence - expert opinion)
1i. A reduction in sugar based medicine will reduce dental decay i.

(Health gain notation - 2 "likely to be beneficial")

i. Maguire A, Rugg-Gunn AJ, Butler TJ. Dental health of children taking antimicrobial and non-antimicrobial liquid oral medication long-term. Caries Research 1996; 30(1): 16-21
(Type III/IV evidence - well designed experimental and observational studies)
1j. Sugar substitutes may be of benefit in reducing dental caries. However, other effects of such substitutes should be understood and taken into accounti,ii.

(Health gain notation - 4 "unknown")

i. Birkhed D. Cariologic aspects of xylitol and its use in chewing gum: A review. Acta Odontologica Scandinavica 1994; 52: 116 - 127
(Type III evidence - well designed trial; not randomised controlled);
ii. Isogangas P, M kinen KK, Tiekso J, Alanen P. Long-term effect of xylitol chewing gum in the prevention of dental caries: a follow-up 5 years after termination of a prevention program. Caries Research 1993; 27: 495 - 498
(Type III evidence - well designed trial : not randomised controlled)
1k. Dietary control of sugars aids prevention of root cariesi.

(Health gain notation - 1 "beneficial")

i. Papas AS, Joshi A, Belanger AJ, Kent Jr RL, Palmer CA, DePaola PF. Dietary models for root caries. American Journal of Clinical Nutrition 1995; 61(suppl): 417S-422S
(Type IV evidence - observational studies)

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1l. The effectiveness of programmes to modify diet remains uncleari.

(Health gain notation - 4 "unknown")

i. Kay EJ, Locker D. Is dental health education effective? a systematic review of current evidence. Community Dentistry and Oral Epidemiology 1996; 24(4): 231-235
(Type I evidence - systematic review using MEDLINE only)
1m. Oral health promotion is more effective when educational approaches are tailored to clients’ needs and when social and physical environments are considered i.
(Health gain notation - 3 "weighted according to individual circumstances")
Further research is recommended to evaluate oral health promotion and education, and to link this to health outcomes.
i. Sprod AJ, Anderson R, Treasure ET. Effective Oral Health Promotion. Literature review. Technical Report 20. Cardiff: Health Promotion Wales, 1996
(Type I evidence - systematic review)
1n. Resin based fissure sealants are effective in preventing dental caries i,ii.

(Health gain notation - 1 "beneficial")

i. Llodra JC, Bravo M, Delgado-Rodriguez M, Baca P, Galvez R. Factors influencing the effectiveness of sealants - a meta-analysis. Community Dentistry and Oral Epidemiology 1993; 21(5): 261-8
(Type I evidence - systematic review)
ii. Ripa LW Sealants revisited: an update of the effectiveness of pit-and-fissure sealants. Caries Research 1993; 27(Suppl 1): 77-82
(Type V evidence - expert opinion)
1o. Guidelines on the prevention of dental caries in children are available i,. i. Faculty of Dental Surgery. National Clinical Guidelines 1997. London: Royal College of Surgeons, 1997
(Recommendations classified according to type of evidence)

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1p. Regular clinical examination is recommended for the early detection of tooth decay, with radiographs to detect caries not visible on examination. The interval between successive clinical and radiographic examinations should vary according to the caries susceptibility of the individuali,ii.

(Health gain notation - 1 "beneficial" )

i.Angmar-Mansson B, ten Bosch JJ. Advances in methods for diagnosing coronal caries - a review. Advances in Dental Research 1993; 7(2): 70-79
(Type V evidence - expert opinion);
ii. Jendresen MD, Allen EP, Bayne SC, Donovan TE, Hansson TL, Klooster J, John CK. Annual review of selected dental literature: report of the Committee on Scientific Investigation of the American Academy of Restorative Dentistry. Journal of Prosthetic Dentistry 1994; 72: 39-77
(Type IV evidence - observational studies)
1q. Regular clinical examination and radiographs (x-rays) are recommended for the continuing care of the restored dentition i.
(Health gain notation - 1 "beneficial" )
The ideal interval between examination and radiography is affected by the oral health of the individual.
i. Oral Health. Protocol for Investment in Health Gain. Welsh Health Planning Forum. Cardiff: Welsh Office NHS Directorate, November 1992
(Type V evidence - expert opinion);
1r. Part of the diagnostic process for dental caries is visual and gentle tactile examination of teeth i.
(Health gain notation - 1 "beneficial")
New methods of diagnosing caries are under development but all require clinical testingii.
(Health gain notation - 4 "unknown")
i. Oral Health. Protocol for Investment in Health Gain. Welsh Health Planning Forum. Cardiff: Welsh Office NHS Directorate, November 1992
(Type V evidence - expert opinion):
ii. Angmar-Mansson B, ten Bosch JJ. Advances in methods for diagnosing coronal caries - a review. Advances in Dental Research 1993; 7(2): 70-79
(Type V evidence - expert opinion)

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1s. Diagnosis of approximal caries can be assisted by using fiber-optic transilluminationi,ii.

(Health gain notation - 4 "unknown")

i. Verdonschot EH, Bronkhorst EM, Wenzel A. Approximal caries diagnosis using fiber-optic transillumination: a mathematical adjustment to improve validity. Community Dentistry and Oral Epidemiology 1991; 19: 329-32
(Type IV evidence - observational studies):
ii. Angmar-Mansson B, ten Bosch JJ. Advances in methods for diagnosing coronal caries - a review. Advances in Dental Research 1993; 7(2): 70-79
(Type V evidence - expert opinion)
1t. Dental amalgam is an effective filling material. Amalgam restorations do not appear to be hazardous to the general health of the populationi,ii,iii.

(Health gain notation - 1 "beneficial"

i. Corbin SB, Kohn WG. The benefits and risks of dental amalgam: current findings reviewed. Journal of the American Dental Association 1994;125: 381-388
(Type III evidence - well designed trial: not randomised controlled);
ii.Eley BM, Cox SW. The release, absorption and possible health effects of mercury from dental amalgam: a review of recent findings (erratum to the original review published on September 11, 1993). British Dental Journal 1993; 175(161): 355-362
(Type III/IV evidence - review of non-randomised trials and observational studies);
iii. Mj r IA, Pakhomov GN (eds.). Dental amalgam and alternative direct restorative materials. Geneva: World Health Organisation, 1997
(Type III/IV evidence - review of non-randomised trials and observational studies)
1u. Dentists should be cautious when using dentine bonding agents because the permanence of the bond in the oral environment has not been extensively studiedi.

(Health gain notation - 2 "likely to be beneficial")

i. Vadiakas GP, Oulis C. A review of dentine-bonding agents and an account of clinical applications in paediatric dentistry. International Journal of Paediatric Dentistry 1994; 4: 209-216
(Type V evidence - expert opinion)
1v. Further research is recommended to validate the use of laboratory predictors of clinical performance of filling materials and to develop an accredited range of products supported by independent research evidencei. i. Internal Review Group

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1w. The success of dentures, bridges and implants is dependent on patient behaviour (eg plaque control) and operator efficiency; therefore the benefit to the patient must be weighed against the risks i.
(Health gain notation - 3 "weighted according to individual circumstances" )
i. Internal Review Group
(Type V evidence - expert opinion)
1x. Correctly made resin bonded bridges are an effective way of replacing missing teeth (survival after 4 years = 74%) i.
(Health gain notation - 1 "beneficial" )
i. Creugers NHJ, Van’t Hof MA. An analysis of clinical studies on resin-bonded bridges. Journal of Dental Research 1991; 70 (2): 146-149
(Type I evidence - systematic review)
1y. Guidelines are available for crown and bridgework i. i. Bennett A. Guidelines for crowns and bridgework. London: British Society for Restorative Dentistry, 1997. http://www/derweb.ac.uk/bsrd/bsrdgde.html
(Type V evidence - expert opinion)
1z. Guidelines are available on the selection of patients to receive treatment with dental implants (priorities for the NHS) and on restorative indications for porcelain veneer restorations i. i. Faculty of Dental Surgery. National Clinical Guidelines 1997. London: Royal College of Surgeons, 1997
(Recommendations classified according to type of evidence)
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Health Evidence Bulletins: Wales, Duthie Library, UWCM, Cardiff CF14 4XN. e-mail: weightmanal@cardiff.ac.uk