R. Gary Rozier, D.D.S., M.P.H.:
Effective caries-preventive methods for use by dental professionals, by individuals, and by public health practitioners have been developed and refined since the introduction of community water fluoridation in the 1940s (U.S. DHHS, 2000). The literature on these methods is extensive. This paper summarizes the evidence for the effectiveness of the preventive methods available to dental professionals and includes professionally administered fluoride, pit-and-fissure dental sealants, antimicrobial agents, and counseling of patients. Counseling can involve a large number of recommended actions to be performed by the patient outside the dental office, such as use of fluoride products, use of antimicrobial agents, oral hygiene practices, and consumption of food containing sugar substitutes. Those are not included in this review.
Review Method
A systematic search of the literature published in English from 1980 through October, 2000, was undertaken in MEDLINE, using the primary search words "caries," "carious," "prevent," "meta-analysis," and "review." EMBASE was searched for the period 1988 through June, 2000, using the same search strategy and keywords. Articles that did not focus on the caries-inhibiting effect of preventive methods were excluded. The 821 articles retrieved through MEDLINE and the 206 in EMBASE were examined for specific preventive methods. A search of nonelectronic sources was also conducted to identify reviews not published in peer-reviewed journal literature.
Search Results Close to 40 reviews were identified that focused on the clinical effectiveness of fluorides, pit-and-fissure sealants, antimicrobial agents, and patient counseling. Four reviews were identified that included multiple preventive methods. The search identified systematic reviews of professionally applied topical fluoride gels (van Rijkom, Truin, van�t Hol, 1998), fluoride varnish (Helfenstein, Steiner, 1994), pit-and-fissure sealants (Llodra, Bravo, 1993), antimicrobials (van Rijkom, Truin, van�t Hof, 1996) and patient counseling (Kay, Locker, 1996; Kay, Locker, 1998; Sprod, Anderson, Treasure, 1996).
Conclusions
The overall preventive effect of professional fluoride gel treatments on caries increments between children treated and children not treated was between 18 and 25 percent. Clinical investigations of the application of fluoride varnish to permanent teeth of children provided preventive effects of between 25 and 50 percent.
Placebo control studies have been deemed unethical since the 1970s because of the almost universal availability of fluoride dentifrices, so few recent studies of professionally applied fluorides have been conducted. Although fluoride is clearly effective in preventing and controlling dental caries, no randomized control trials of the incremental benefit of in-office fluoride treatment for low-risk patients also exposed to fluoridated toothpaste and other sources of fluoride have been reported. Estimates of the number of patients needed for treatment with gels or varnishes to prevent a cavity (1 DMF) suggest that the additional effect of professional fluoride treatments is low in patients who are at reduced risk for dental caries. Little information is available on the caries-inhibiting effects of professional applied topical fluoride treatments in populations other than children.
The literature offers strong evidence that sealants are effective in preventing pit-and-fissure caries. The overall effectiveness of autopolymerized fissure sealants was between 69 and 72 percent. No studies have reported on the preventive effects of sealant according to caries risk status. However, estimates of the number that would have to be treated suggest that the benefit in populations at low-risk for of pit-and-fissure caries may be low.
Antimicrobial agents have been employed in high-risk patients for short periods to reduce or eliminate decay-causing bacteria. Chlorhexidine gel, the most commonly used agent in office-based care, is effective in the prevention and control of dental caries. The overall caries-inhibiting effect of chlorhexidine is between 35 and 57 percent.
A number of effective preventive methods are available to the public for individual use. The evidence on patient counseling suggests that dental knowledge can be improved with health promotion and counseling activities. However, a causal link between professional counseling in a clinical setting and use of caries-preventive methods at home has not been established.
References
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Kay E, Locker D. Is dental health education effective? A systematic review of current evidence. Comm Dent Oral Epidemiol 1996;24:231�5.
Kay E, Locker D. A systematic review of the effectiveness of health promotion aimed at improving oral health. Community Dent Health 1998;15:132�44.
Llodra JC, Bravo M, Delgado-Rodgriquez M, Baca P, Galvez R. Factors influencing the effectiveness of sealants�a meta-analysis. Comm Dent Oral Epidemiol 1993;21:261�8.
Sprod AJ, Anderson R, Treasure ET. Effective oral health promotion: literature review. Technical Report 20, Cardiff: Health Promotion. University of Wales College of Medicine, Cardiff, 1996.
U.S. Department of Health and Human Services. Oral health in America: a report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.
van Rijkom HM, Truin GJ, van�t Hof MA. A meta-analysis of clinical studies on the caries-inhibiting effect of chlorhexidine treatment. J Dent Res 1996;75:790�5.
van Rijkom HM, Truin GJ, van�t Hof MA. A meta-analysis of clinical studies on the caries-inhibiting effect of fluoride gel treatment. Caries Res 1998;32:83�92.