Observación

• Systematic reviews locate, appraise, and synthesize evidence from scientific studies in order to provide informative answers to scientific research questions

• They are valuable sources of information for decision makers

• Systematic review adhere to a strict scientific design, with the aim of making them more comprehensive, minimizing the chance of bias and improving reliability

• A systematic review should contain a comprehensive assessment and summary of the available evidence

Figure 3.17 Bone fracture incidence. (Measure of effect estimate and 95% CI.) (NHS Centre for Reviews and Dissemination: Report 18.)

Figure 3.18 Mean difference of the change in dmft/DMFT in the exposed (fluoride) compared with the control group (low fluoride), separately by age (color coded) for the four studies reporting dmft/DMFT, with 95% CIs. Fifteen studies found a statistically significantly greater mean change in dmft/DMFT scores in the fluoridated areas than the non-fluoridated areas. The range of mean change in

dmft/DMFT score was from 0.5 to 4.4, median 2.25 teeth (interquartile range 1.28, 3.63 teeth). (NHS Centre for Reviews and Dissemination: Report 18.)

Wragg (1992)

Artwood (1988)

Kalsbeek (1993)

Kalsbeek (1993)

−25 −15 −5

Favours floridated

dmft score DMFT score DMFS score

Favours non-fluoridated

0 5

Seppa (1998) Age 9

Seppa (1998) Age 12

Seppa (1998) Age 15

Figure 3.19 Mean difference of the change in the dmft/DMFT and DMFS score in children in the exposed (fluoride) group compared with the control group (low fluoride), in studies in which fluoridation was discontinued after the baseline survey. (NHS Centre for Reviews and Dissemination: Report 18.)

so many decayed teeth with the dental resources available at present in the developing countries, the only hope is to contain the caries problem by preventive measures.

2. The Conference agreed that community water fluoridation is an ideal measure for the prevention of dental caries in countries with well-developed, centralized public water supplies. It was in agreement with the view of the FDI, WHO, and the medical and dental professions throughout the world that community water fluoridation is an effective, safe, and inexpensive preventive measure, which has the virtue of requiring no active compliance on the part of the persons benefited. The Conference recommended that com-munity water fluoridation be introduced and maintained wherever possible.

3. Unfortunately, the vast majority of the world’s population live in rural and urban areas with few large water installations. In these situations, community water fluoridation is not feasible and alternative strategies need to be adopted. There is evidence from three long-term studies in both developing and industrialized countries that fluoridized salt may be nearly as effective as water fluoridation in reducing the incidence of dental caries. Consequently, the Conference stressed the need for more long-term field trial of salt fluoridization.

4. There is no justification for using more than one systemic fluoride measure at any one time.

5. Various topical fluoride methods, or combinations of such methods, may be beneficial in communities that have a source of systemic fluoride that is used widely.

6. Wherever possible, when combinations of fluoride therapy are considered, it is best to choose those that are self-admin-istered or group-adminself-admin-istered because they are less expensive.

7. Professionally applied fluorides are particularly appropriate for individuals who have been identified as at high risk of dental caries.

8. The conference was concerned about the problems of dental fluorosis in areas with high concentrations of fluoride in the public water supply and urged research to develop effective, simple, and economical defluoridation methods for water supplies of varying sizes. It recommended that, in children under the age of 6 years, brushing with a fluoride tooth-paste should be supervised in order to prevent excessive ingestion. For similar reasons, fluoride mouth rinsing should not be considered for children under 5 years of age.

9. Current knowledge of the effectiveness of various methods of using fluorides led the Conference to conclude that each country should review its own dental needs and take leg-islative action to adopt those methods of using fluorides that best suit its needs in different regions. In view of the proven value of fluorides in promoting dental health, their use should be extended without further delay to all popula-tions throughout the world.

WHO considered the subject again in 1993. The expert working group made a number of recommendations, including the following

• The effectiveness of all caries preventive programmes should be monitored on an ongoing basis.

• Community water fluoridation is safe and cost-effective and introduced and maintained wherever socially acceptable and feasible. The optimum water fluoride concentration will normally be within the range 0.5–1.0 mg/L.

• Salt fluoridization, at a minimum concentration of 200 mg/L F, should be considered as a practical alternative to water fluoridation.

• Encouraging results have been reported with fluoridization of milk but more studies are recommended.

• Fluoride supplements have limited application as a public health measure. In areas with medium to low caries experience a conservative prescribing policy should be adopted; a dose of 0.5 mg F/day should be prescribed for at-risk individuals from the age of 3 years. In areas with high caries experience a regi-men starting at 6 months of age, taking into account the flu-oride content of the drinking water, should be used.

• Only one systemic fluoride measure should be used at any one time.

• Because fluoride toothpaste is a highly effective means of caries control, every effort must be made to develop afford-able fluoride toothpastes for use in developing countries.

Measures should be taken to exempt fluoride toothpastes from duties and taxation.

• Fluoride toothpaste tubes should contain advice that, for children under 6 years of age, brushing should be supervised and only a minimal amount (less than 5 mm) should be placed on the brush or chewing stick. Toothpastes with low-ered levels of fluoride, manufactured especially for use by children, should be fully studied.

• Toothpastes with candy-like flavours, and toothpaste con-taining 1500 ppm or more are not recommended for use by children under 6 years of age.

• In low fluoride communities, school-based brushing and mouthrinsing programmes are recommended, but their adoption should be based on the cost of implementation and the caries status of the community. Fluoride mouthrins-ing is contraindicated in children under 6 years of age.

• Further research on the effectiveness of fluoride on root sur-face caries is recommended.

• Dietary practices that increase the risk of infants and young children being over-exposed to fluoride from all sources should be identified and appropriate action taken.

• Dental fluorosis should be monitored periodically to detect increasing or higher than acceptable levels of fluorosis.

Action should be taken when fluorosis is found to be exces-sive by adjusting fluoride intake from water, salt, or other

current fluoride exposure to predict further risk of fluorosis.

Conclusions

The study of the systemic and topical effects of fluoride has pro-duced a tremendous outpouring of research, particularly over the last 50 years, and our knowledge of dental epidemiology, clinical trials, community dental health, dental plaque, physiology, and biochemistry has increased enormously as a result. This chapter has concentrated on water fluoridation, fluoridization of salt and milk, fluoride supplements, fluoride dentifrices, and dental fluorosis.

The incorporation of fluoride in its various forms as a caries-preventive agent for both the individual and the community, is one of the most important factors responsible for the decrease in dental caries in children observed in many industrialized countries.

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