Evidence-based guidance on the use of topical fluorides for caries prevention in children and adolescents in Ireland TOPICAL FLUORIDES Evidence-based guidance on the use of topical fluorides for caries prevention in children and adolescents in Ireland This work was funded by the Health Research Board (Grant No. S/A013) Recommended citation: Irish Oral Health Services Guideline Initiative. Topical Fluorides: Evidence-based guidance on the use of topical fluorides for caries prevention in children and adolescents in Ireland. 2008 Guideline and supplementary data available at: http://ohsrc.html/guidelines.html What is an evidence-based guideline? Evidence-based clinical practice guidelines are systematically developed statements containing recommendations for the care of individuals by healthcare professionals that are based on the highest quality scientific evidence available. Guidelines are designed to help practitioners assimilate, evaluate and apply the ever-increasing amount of evidence and opinion on current best practice, and to assist them in making decisions about appropriate and effective care for their patients. Their role is most clear when two factors are present: (a) evidence of variation in practice that affects patient outcomes, and (b) a strong research base providing evidence of effective practice.1 It is important to note that guidelines are not intended to replace the healthcare professional’s expertise or experience, but are a tool to assist practitioners in their clinical decision-making process, with consideration for their patient’s preferences. To assist the reader of this guideline, the key to the grading of evidence and recommendations is presented below. LEVELS OF EVIDENCE 1++ High quality meta-analysis, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias 1+ Well conducted meta-analyses, systematic reviews or RCTs with a low risk of bias 1- Meta-analyses, systematic reviews or RCTs with a high risk of bias 2++ High quality systematic reviews of case-control or cohort studies High quality case-control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal 2+ Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal 2- Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal 3 Non-analytic studies, e.g. case reports, case series 4 Expert opinion GRADES OF RECOMMENDATIONS A At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population OR A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results B A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results OR Extrapolated evidence from studies rated as 1++ or 1+ C A body of evidence including studies rated as 2+, directly applicable to the target population, and demonstrating overall consistency of results OR Extrapolated evidence from studies rated as 2++ D Evidence level 3 or 4 OR Extrapolated evidence from studies rated as 2+ GPP Recommended best practice based on the clinical experience of the Guideline Development Group Good Practice Point Reproduced with permission from SIGN guideline development handbook, SIGN 50 (http://www.sign.ac.uk/methodology/index.html) 1 Acknowledgements Guideline Development Group Padraig Creedon Chair, Principal Dental Surgeon, HSE South Deirdre Browne Oral Health Services Research Centre, Cork Evelyn Connolly Senior Dental Surgeon (Paediatric), HSE Dublin North East Bridget Harrington-Barry Public Dental Surgeons’ Group, Irish Dental Association Dr Dympna Kavanagh Principal Dental Surgeon, HSE West (Sept 2006–Apr 2008) Professor Denis O’Mullane Expert Body on Fluorides and Health Siobhan O’Shea Dental Hygienist, HSE South Mary Ormsby Principal Dental Surgeon, HSE Dublin North East Michelle Spearman-Geraghty Senior Dental Nurse, HSE West Research Team Carmel Parnell Lead Researcher, Oral Health Services Research Centre/ Senior Dental Surgeon (Dental Public Health), HSE Dublin North East Patrice James Researcher, Oral Health Services Research Centre, Cork Helena Guiney Researcher, Oral Health Services Research Centre, Cork Virginia Kelleher Copy Editor, Oral Health Services Research Centre, Cork Dr Noel Woods Lecturer in Economics, Centre for Policy Studies, University College Cork Una Ni Chonghaile Information Scientist, Medical Library, Cork University Hospital Guideline Project Team Professor Helen Whelton Principal Investigator, Director, Oral Health Services Research Centre, Cork Dr Paul Beirne Department of Epidemiology and Public Health, University College, Cork Professor Mike Clarke Director, UK Cochrane Centre; School of Nursing and Midwifery, Trinity College Dublin Mary O’Farrell Principal Dental Surgeon, HSE Dublin North East Mary Ormsby Principal Dental Surgeon, HSE Dublin North East External Reviewers Dr Jan Clarkson Director of the Effective Dental Practice Programme, Honorary Consultant in Paediatric Dentistry, Dental Health Services Research Unit, University of Dundee Professor Amid Ismail Department of Cariology, Restorative Sciences and Endodontics, School of Dentistry, University of Michigan Dr Valeria Marinho Senior Lecturer in Bioinfomatics, Institute of Dentistry, Queen Mary University of London Professor John Spencer Professor of Social and Preventive Dentistry, University of Adelaide Professor Helen Worthington Professor of Evidence-Based Care, University of Manchester Acknowledgements We would like to thank the following for their contribution to this guideline: Sylvia Bickley, Trials Search Co-ordinator, Cochrane Oral Health Group, Manchester; Dr Morag Curnow, Clinical Dental Director, Community Dental Service, Perth, Scotland; Dr Gill Davis, Department of Dental Public Health, Manchester Primary Care Trust; Sarah Hall, PhD student, University College Cork.; Dr Valeria Marinho, Senior Lecturer in Bioinfomatics, Institute of Dentistry, Queen Mary University of London. Our thanks also to the staff of the Oral Health Services Research Centre for their assistance in hosting the Guideline Development Group meetings. 2 Contents WHAT IS AN EVIDENCE-BASED GUIDELINE? ............................................................................................ 1 ACKNOWLEDGEMENTS .................................................................................................................................... 2 CONTENTS ........................................................................................................................................................... 3 SUMMARY OF RECOMMENDATIONS ............................................................................................................ 5 SECTION 1: BACKGROUND .............................................................................................................................. 8 1.1 EPIDEMIOLOGY .............................................................................................................................................. 8 1.1.1 Dental caries ........................................................................................................................................ 8 1.1.2 Dental fluorosis .................................................................................................................................... 9 1.2 WHY DO WE NEED A GUIDELINE? .................................................................................................................. 12 SECTION 2: METHODOLOGY ......................................................................................................................... 14 2.1 SCOPE OF THE GUIDELINE ............................................................................................................................ 14 2.1.1 What the guideline covers ................................................................................................................... 14 2.1.2 What the guideline does not cover ...................................................................................................... 14 2.2 AIM OF THE GUIDELINE ................................................................................................................................ 15 2.3 GUIDELINE METHODOLOGY .......................................................................................................................... 15 2.3.1 Guideline Development Group ........................................................................................................... 15 2.3.2 Questions addressed by the guideline ................................................................................................. 15 2.4 SEARCH STRATEGY ........................................................................................................................................ 16 2.5 FUNDING FOR THE GUIDELINE ...................................................................................................................... 18 2.6 UPDATING THE GUIDELINE ........................................................................................................................... 18 SECTION 3: DENTAL CARIES AND THE ROLE OF FLUORIDE IN CARIES PREVENTION ............... 19 3.1 INTRODUCTION