Impact story: Fluoride varnishes and fissure sealants for preventing caries in children and adolescents

In 2013, Cochrane Oral Health updated their reviews on fluoride varnishes and different types of fissure sealants for preventing caries in children and adolescents. The varnish update included 22 trials, while the sealants update included 34. There were no changes to the conclusions. Both reviews confirmed the caries-inhibiting effects of both fluoride varnishes and sealants. A review comparing both interventions was then updated in 2016 including 8 trials, indicating the superiority of resin-based fissure sealants in preventing caries when applied to the biting surfaces of permanent back teeth in children. 

These reviews have received plenty of media attention. For example, a post on our blog on Sealants versus fluoride varnish – which is better for preventing decay in children’s teeth?1 was the most popular post in 2016 and its publication on 22nd January 2016 coincided with our busiest day of the year for the blog with 1,908 views in one day. Likewise, one of the Facebook posts with the most reach in 2016 was ‘Newly updated Cochrane evidence - which is better for your children's teeth - sealants or fluorides varnishes?’ (8,732 people reached, shared 53 times, posted 19th January 2016). In September 2016, the New York Times’ article ‘Defending your children’s teeth (and dentists): the value of sealants2 was based on, and cited, our review.

Over the years, these reviews and their findings have also been the core for numerous international guidelines and have been used in policy/decision making at many levels (e.g. international, national, regional, local trust or unit, professional) of the health service. A few examples follow:

  • American Association for Dental Research (AADR)3,4 
  • Irish Oral Health Services Guideline Initiative5,6
  • Scottish Dental Clinical Effectiveness Programme (SDCEP)7
  • NHS East London and the City8
  • American Dental Association9
  • Canadian Federal, Provincial and Territorial Dental Working Group10
  • South Australia Dental Service, Government of South Australia11
  • Latvian Dental Hygienists Association12
  • National Institute for Health and Care Excellence (NICE)13
  • American Academy of Pediatric Dentistry (AAPD)14,15
  • Association of the Scientific Medical Societies in Germany (AWMF)16
  • Community Paediatrics Committee of the Canadian Paediatric Society17 
  • First Nations, Inuit and Métis Health Committee of the Canadian Paediatric Society18 

But most significantly these reviews have not only led to subsequent research, but this research into the translation of evidence into practice has led to change in policy and practice:

  • In Scotland, for example: “Fluoride varnish should be applied at least twice yearly in all children […]. Resin-based fissure sealants should be applied to the permanent molars of all children as early after eruption as possible.19
  • Cochrane Oral Health collaborated with Public Health England on the compilation of ‘Delivering Better Oral Health: An Evidence-Based Toolkit for Prevention’20, a key document on prevention of oral health problems that was commissioned by the Department of Health to develop public health guidance for local authorities, dental health practitioners and carers working in health and social residential care. Cochrane Oral Health’s expert advice is acknowledged within the document as is our review of the draft document. Both our Co-ordinating Editor Jan Clarkson and Editor Ian Needleman are members of the working group. We have had discussions with the authors and provided comments on the most recent update of this publication (which incorporates results from a number of our reviews not just those on varnishes/sealants). 
    • It should be noted that the publication of the toolkit in 2007 led to a range of positive changes that have increased the likelihood of people in England benefiting from improved oral health.
    • For example, the guidance states the minimum concentrations of fluoride in toothpaste to control caries and prompted several manufacturers to reformulate their children’s toothpaste to a more effective level for caries control.
    • Guidance regarding the important role of fluoride varnish as part of clinical activity to control caries has led to a large increase in the number of primary care teams applying this routinely and regularly to their child patients and to adults at higher risk. No doubt this is likely to lead to lower caries levels among children, adolescents and adults.
    • The toolkit has proved useful in ensuring that consistent advice is given as part of preventively orientated treatment plans and has improved coherence between dental teams and other agencies (commissioners and other health, education and social care work partners). Cochrane Oral Health is very pleased with these positive effects and aim to input further in subsequent updates.

Read the full reviews:

Citations:

  • 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
  • Ahovuo-Saloranta A, Forss H, Walsh T, Hiiri A, Nordblad A, Mäkelä M, Worthington HV. Sealants for preventing dental decay in the permanent teeth. Cochrane Database of Systematic Reviews 2013, Issue 3. Art. No.: CD001830. DOI: 10.1002/14651858.CD001830.pub4
  • Ahovuo-Saloranta A, Forss H, Hiiri A, Nordblad A, Mäkelä M. Pit and fissure sealants versus fluoride varnishes for preventing dental decay in the permanent teeth of children and adolescents. Cochrane Database of Systematic Reviews 2016, Issue 1. Art. No.: CD003067. DOI: 10.1002/14651858.CD003067.pub4 

Footnotes

1 https://cochraneohg.wordpress.com/2016/01/19/sealants-versus-fluoride-varnish-which-is-better-for-preventing-decay-in-childrens-teeth/

2 https://www.nytimes.com/2016/09/20/upshot/defending-your-childrens-teeth-and-dentists-the-value-of-sealants.html

3 American Association for Dental Research (AADR). Policy Statements: Sealants. AADR Executive Committee. 2009 http://www.aadronline.org/i4a/pages/index.cfm?pageid=3465#SEALANTS 

4 American Association for Dental Research (AADR). Policy Statements: Topical Fluorides. AADR Executive Committee. 2009. http://www.aadronline.org/i4a/pages/index.cfm?pageid=3465#TOPICAL_FLUORIDES 

5 Irish Oral Health Services Guideline Initiative. Strategies to prevent dental caries in children and adolescents: Guidance on identifying high caries risk children and developing preventive strategies for high caries risk children in Ireland. Guideline Development Group. 2009. http://www.ucc.ie/en/ohsrc/publications-guidelines/

6 Irish Oral Health Services Guideline Initiative. Pit and Fissure Sealants: Evidence-based guidance on the use of sealants for the prevention and management of pit and fissure caries. Guideline Development Group. 2010. http://www.ucc.ie/en/ohsrc/publications-guidelines/

7 Scottish Dental Clinical Effectiveness Programme (SDCEP). Prevention and Management of Dental Caries in Children: Dental Clinical Guidance. 2010. http://www.sdcep.org.uk/published-guidance/caries-in-children/ 

8 NHS East London and the City. Oral health of Children: Tower Hamlets Joint Strategic Needs Assessment 2010-2011. Joint Strategic Needs Committee. 2011.  

9 American Dental Association. Rethman MP, Beltrán-Aguilar ED, Billings RJ, Hujoel PP, Katz BP, Milgrom P, et al. Nonfluoride caries-preventive agents: Executive summary of evidence-based clinical recommendations. J Am Dent Assoc. 2011;142(9):1065-1071

10 Canadian Federal, Provincial and Territorial Dental Working Group. Preventive Programming Guidelines for Community-Based Dental Health Programs: Options for Your Community. Hayes, A for the Office of the Chief Dental Officer. 2012. 

11 South Australia Dental Service, Government of South Australia. Health Promotion Practice Guidelines 2012-2015. 2012. http://www.sadental.sa.gov.au/DesktopDefault.aspx?tabid=457

12 Latvian Dental Hygienists Association. Maldupa I et al, 2014. [Guidelines for the use of fluoride in Latvia], Fluoridu lietosanas vadlinijas Latvija [ebook], http://zobuhigienisti.lv/attachments/article/62/Fluoridu%20lietosanas%20vadlinijas%20Latvija.pdf

13 National Institute for Health and Care Excellence (NICE). Oral health: approaches for local authorities and their partners to improve the oral health of their communities (NICE Public Health Guidance 55). London: National Institute for Health and Care Excellence; 2014. [Issued October 2014]. http://www.nice.org.uk/Guidance/PH55 

14 American Academy of Pediatric Dentistry (AAPD). Guideline on Adolescent Oral Health Care. Chicago (IL): The American Academy of Pediatric Dentistry; 2015. http://www.aapd.org/media/Policies_Guidelines/G_Adoleshealth.pdf

15 American Academy of Pediatric Dentistry (AAPD). Guideline on Restorative Dentistry. Chicago (IL): The American Academy of Pediatric Dentistry; 2016. http://www.aapd.org/media/Policies_Guidelines/G_Restorative1.pdf 

16 Association of the Scientific Medical Societies in Germany (AWMF). Geurtsen W, Hellwig E, Klimek J, Beck J, Benz C, Bertzbach F, et al. Kariesprophylaxe bei bleibenden Zähnen – grundlegende Empfehlungen. [Caries prophylaxis for permanent teeth - basic recommendations]. Düsseldorf: Deutsche Gesellschaft für Zahn-, Mund- und Kieferheilkunde (DGZMK) und Deutsche Gesellschaft für Zahnerhaltung (DGZ); 2016. http://www.awmf.org/leitlinien/detail/ll/083-021.html

17 Rowan-Legg A, on behalf of the Community Paediatrics Committee of the Canadian Paediatric Society. Oral health care for children – a call for action [issued 2013, reaffirmed Feb 2016]. Paediatr Child Health 2013;8(1):37-43. http://www.cps.ca/en/documents/position/oral-health-care-for-children

18 Irvine JD, Holve S, Krol D, Schroth R, on behalf of the First Nations, Inuit and Métis Health Committee of the Canadian Paediatric Society. Early childhood caries in Indigenous communities (A joint statement with the American Academy of Pediatrics). [issued 2011, reaffirmed Feb 16]. Paediatr Child Health. 2011;16(6):351-7. http://www.cps.ca/documents/position/oral-health-indigenous-communities 

19 Scottish Intercollegiate Guidelines Network (SIGN), 2014. SIGN 138 Dental interventions to prevent caries in children: a national clinical guideline http://www.sign.ac.uk/pdf/SIGN138.pdf 

20 Public Health England. Delivering better oral health: an evidence-based toolkit for prevention (3rd edition). London: Public Health England; 2017 March. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/601832/delivering_better_oral_health.pdf.