Topical fluoride guidance

Abstract

Scope and purpose

To review the scientific evidence and develop clinical recommendations on professionally applied topical fluoride.

Methodology

Medline and the Cochrane Database of Systematic Reviews were searched for systematic reviews published in the English language that dealt with professionally applied topical fluoride, including gel, foam or varnish, at any time up to October 2005. Seventeen systematic reviews were identified. Clinical studies published after January 2004 and thus not included in the systematic reviews were also identified through Medline. The American Dental Association (ADA) Council on Scientific Affairs formed a panel of experts to evaluate the identified systematic reviews and clinical trials. The panellists were provided with the identified publications and asked to identify any additional systematic reviews or other relevant published trials. One additional publication was included that had been accepted for publication. The individual studies were assessed at a workshop and a draft document was submitted for review to scientists with expertise in fluoride and caries, relevant ADA agencies and the external reviewers. The comments received were considered by the expert panel and the clinical recommendations were approved by the ADA Council on Scientific Affairs. The evidence (Table 1) and strength of recommendations (Table 2) were graded as shown.

Table 1 System used for grading evidence

Table 2 System used for classifying strength of recommendations

Review and Updating

A date for the review of the recommendation is not provided.

Recommendations

The panel produced a number of evidence statements (Table 3) and recommend planning topical fluoride applications based on an assessment of a patient's clinical risk (Table 4): a summary of the main clinical recommendations is shown in Table 5. The full document and an executive summary can be downloaded (www.ada.org/prof/resources/topics/evidencebased.asp).

Table 3 Evidence statements and levels

Table 4 Clinical risk criteria

Table 5 Summary of main clinical recommendations

Research recommendations

A number of areas were identified as requiring additional research:

• A systematic review on the effectiveness of fluoride varnish and gel in high-risk people and/ or groups and the effects of varied frequency

• The effects of frequency and mode of application (varnish, gel and foam) of fluoride products in adults and especially in populations with special needs

• The use of fluoride varnish and gel for the prevention of root caries and recurrent caries

• Strategies, especially for appropriate intervals of fluoride varnish and gel in high-risk groups, including consideration of multiple applications over short time intervals

• The best fluoride regimen to assist in the remineralisation of early carious lesions

• Clinical trial on the effects of fluoride foam versus gel in various target populations

• Clinical trial on the effectiveness of 1-min versus 4-min gels in various target populations

• Development of slow-release fluoride systems that are responsive to changing pH levels in plaque fluid and/ or saliva

• Methods of assessing caries risk

• The safety and effectiveness of chewable topical fluoride supplements or troches for adults

• Evaluation of whether the caries-prevention effect of topical fluoride treatments is influenced by fluoridated water and toothpastes

Commentary

The ADA have been increasingly active in supporting evidence-based dentistry since developing a definition and policy for this approach to practice. This, their first evidence-based clinical recommendation, is another welcome development.

This evidence-based clinical recommendation conforms to the definition of clinical practice guidelines, as outlined by Field and Lohr, as “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”¹ As with most other guidelines that have been produced, there is a clear statement that these recommendations are not a standard of care, requirements or regulations, and that they must be balanced with the practitioner's professional judgment and the individual patient's preferences. This balancing of the evidence (in this case the guideline), professional judgement and the patients' preferences are at the heart of the evidence-based approach.

The scope and purpose of the guideline are clear and there has been widespread consultation with professional groups in both the US and UK, although there is no indication of patient involvement in the development of this recommendation. Patient involvement in guideline development is recommended in the AGREE (Appraisal of Guidelines Research and Evaluation) methodology (www.agreecollaboration.org) and is being used in guidelines under development with bodies such as the Scottish Intercollegiate Guidelines Network (SIGN) and NICE (National Institute for Health and Clinical Excellence) in the UK.

The AGREE appraisal instrument has a number of questions about the rigour of the guideline development and, although it is clear that the approach to the development of this guideline has been systematic, some of the fine detail is missing regarding the search methodology, selection criteria and methods of formulating the recommendation. I am aware that more of this detail was available in the consultation document but it is not in this published version.

The links between the supporting evidence and the recommendations are clearly presented and external review has been undertaken. There is, however, no indication as to whether the guidance will be reviewed and or updated in the future. The availability of an executive summary is helpful, particularly the Table summarising the recommendations.

The article touches briefly on a lack of definition in payment systems for the use of fluoride products to prevent early carious lesions from progressing, but it does not indicate how these or other barriers to adopting the recommendation should be addressed. SIGN and NICE guidelines provide suggestions for auditing and monitoring compliance and perhaps these could be considered in future guidance.

The clinical recommendations are well supported by the evidence and accord well with the two existing evidence-based guidelines on caries prevention available from SIGN.^{2, 3} A useful extension to these is that this guidance includes the evidence relating to people over 18 years of age. It is worth noting, however, that these recommendations are based on weaker evidence, largely extrapolated from the data available for the effectiveness of topical fluoride in the younger age groups.

In practice, although the use of both gels and varnishes is effective, ease of use and better patient acceptance of varnish means that my personal preference would be the use of the varnish.