REVIEWER
SUMMARY
Selection Criteria
PURPOSE/QUESTION
The purpose of this executive summary
report is to present recommendations
regarding professionally applied and
prescription-strength home-use topical
fluoride products for caries prevention in
children and adults based on a
systematic review of trials. It updates the
American Dental Association (ADA)
2006 clinical recommendations on
topical fluorides
SOURCE OF FUNDING
The American Dental Association
(ADA) Council on Scientific Affairs
(CSA) Expert Panel on Topical Fluoride
Agents commissioned this study, which
was supported in part by the Centers for
Disease Control and Prevention.
TYPE OF STUDY/DESIGN
A clinical practice guideline which
includes a supporting systematic review
(with meta-analysis of trials data) upon
which the recommendations are based
LEVEL OF EVIDENCE
Level 1: Good-quality, patient-oriented
evidence
STRENGTH OF
RECOMMENDATION GRADE
Grade A: Consistent, good-quality
patient-oriented evidence
J Evid Base Dent Pract 2014;14:120-123
1532-3382/$36.00
2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jebdp.2014.07.011
Main Results
Conclusions
The systematic review included 71 trials (from 82 published papers) on the various relevant topical fluoride
treatment agents for preventing caries, with meta-analysis
being undertaken where appropriate.
Based on the review findings, the expert panel concluded
that some professionally applied and prescription-strength
topical fluoride agents are efficacious in preventing and
controlling caries. These products include 2.26% fluoride varnishes, 1.23% fluoride gels, prescription-strength,
home-use 0.5% fluoride gels/pastes, and prescriptionstrength, home-use 0.09% fluoride mouthrinses. The review panel did not find that 0.1% fluoride varnishes or
prophylaxis pastes containing fluoride were efficacious in
preventing caries, and found insufficient evidence on the
efficacy of 1.23% fluoride foams in caries prevention.
The panel found insufficient evidence on the comparative caries-preventive efficacy of topical fluoride agents,
no caries-preventive benefit from conducting a prophylaxis prior to APF gel (1.23% fluoride) application, and
no evidence on the effect of prior prophylaxis for other
topical fluoride agents.
The main clinical recommendations for people at high
caries risk were:
In short, based on the summary of results from the supporting systematic review, which included meta-analyses of
trial data on the various topical fluoride caries preventive
agents, evidence statements were developed with a corresponding level of certainty (high, moderate, or low) for
each relevant fluoride agent according to age group or
dentition affected. The clinical recommendations for
their use were then developed for each age group, and
the strength of the recommendations was graded according to a standardized process. It balanced level of certainty
and net benefit rating (based on the balance of benefits
and potential harms) to arrive at recommendation
strength. Recommendations for future research were
also developed.
the full report that clinically relevant outcomes considered from the outset in the guideline, included caries
increment, arrest, and reversal, and that only caries increment was ultimately addressed in the recommendations
due to insufficient evidence on the others. Thus the relative values of the outcomes could not be weighed in terms
of importance. It is also pointed out in the full report that
three clinical questions are addressed in the study, but
because insufficient evidence was found on one of the
questions the comparative effectiveness of different
topical fluoride agents it was not considered further.
Here, a relevant Cochrane review 4 that compiles experimental evidence on this comparison might have been
considered among the reviews used in the guideline as
a source to identify relevant trials for the supporting
review.
The full report also exposes areas where some refinements could have been beneficial in the conduct of the
systematic review and the subsequent interpretation of
the evidence. With this regard, issues on the searches performed to locate primary studies for the review and on the
methods adopted to compile and summarize some of the
data in the review may have had an impact on the data
available (or lack of data) for analysis and on how these
were used in the recommendations. For example, relevant trials may have gone unidentified for the supporting
review because the search is limited to studies in the English language, where only two databases appear to have
been searched, and because the strategy could probably
have been more sensitive. On the other hand, irrelevant
trial arms may have contributed results for analysis
because positive control group data that did not address
the questions posed in the systematic review appear to
have been pooled.
Because caries prevention is an area in which a sizeable
body of evidence is compiled systematically by the
REFERENCES
1. Shiffman RN, Shekelle P, Overhage JM, Slutsky J, Grimshaw J,
Deshpande AM. Standardized reporting of clinical practice guidelines: a proposal from the conference on guideline standardization.
Ann Intern Med 2003;139:493-8.
2. Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging
consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336:924-6.
3. Scottish Intercollegiate Guidelines Network (SIGN). Dental Interventions to Prevent Caries in Children. Edinburgh: SIGN; 2014 (SIGN
publication no. 138).
4. Marinho VCC, Higgins JPT, Sheiham A, Logan S. One topical fluoride
(toothpastes, or mouthrinses, or gels, or varnishes) versus another for
preventing dental caries in children and adolescents. Cochrane Database Syst Rev 2004;(1):CD002780.
REVIEWER
Valeria C.C. Marinho, BDS, MSc, PhD
Senior Lecturer, Institute of Dentistry, Barts and The London
School of Medicine and Dentistry, Queen Mary University of
London, Turner Street, Whitechapel, London E1 1BB, UK,
Tel.: 44 (0)20 7882 8671
v.marinho@qmul.ac.uk
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