Periodic health examination, 1995 update: 2. Prevention of dental caries

Table 3: Summary of manoeuvres, effectiveness, levels of evidence and recommendations for the prevention of dental caries

Manoeuvre Effectiveness Level of evidence* Recommendation*

Drinking-water fluoridation (1.0-1.2 ppm) Reductions in the incidence of dental caries of 20% to 40% have been reported Prevention of coronal caries; well-designed and controlled community trials without randomization [19,48] (II-1) Good evidence that water fluoridation is the most effective, equitable and efficient preventative for coronal and root dental caries (A)

Daily fluoride supplementation (only where fluoride levels in drinking water are 0.3 ppm or less) Reductions in the incidence of caries in children similar to those achieved by drinking-water fluoridation have been reported; however, parent compliance in providing children with daily supplements is poor Nonrandomized controlled trials [51,56] (II-1). The new lower dosage schedule approved by the Canadian Dental Association has not been subjected to clinical trials Good evidence of reductions in the incidence of decay if the proper dosage schedule is carefully followed; however, inappropriate prescribing of excess fluoride supplements is the main factor in recent increases in the incidence of fluorosis (A)

Annual or biannual professional application of topical fluorides such as acidulated phosphate fluoride gel+ This is a labour-intensive and expensive procedure that is not effective and efficient for most patients in communities with fluoridated or nonfluoridated drinking water. It is effective if used selectively Prevention of coronal caries: randomized controlled trials (RCTs) involving mainly children and adolescents and conducted before the incidence of caries had declined [57] (I)
Prevention of root caries and excess caries resulting from reduced salivary flow caused by radiation therapy or chemotherapy: professional opinion [57] (III)
Good evidence to support this procedure for those with very active decay or at a high risk of caries, since caries in these groups mimic that in the general population before the incidence of caries had declined (A)
Poor evidence to include this procedure in periodic dental examinations for the general population, but it may be recommended for individual patients on other grounds (C)

Prophylaxis (cleaning) before professional application of a topical fluoride Study results show that the incidence of dental caries is equivalent with or without prophylaxis RCTs [21,57] (I) Good evidence to recommend that such prophylaxis be excluded from periodic dental examinations (E)

Use of fluoride mouth rinses (containing 0.20% sodium fluoride, weekly, or 0.05% sodium fluoride, daily) Statistically and clinically significant reductions in the incidence of caries were previously reported; however, in an era if declining incidence, the effectiveness of this procedure for most children is questionable Older, randomized trials involving schoolchildren and more recent trials [57,62] (I)
Recent over-the-counter fluoride mouth rinses for home use have not been well evaluated [60] (III)
Good evidence for use of this manoeuvre for those with very active decay or a high risk of caries (A)
Poor evidence to recommend this manoeuvre for the general population, but it may be recommended for individual patients on other grounds
Good evidence to recommend against the home use of over-the-counter fluoride mouth rinses for the general population (E)

Use of self-applied fluoride dentifrices+ Daily use results in statistically significant reductions in the incidence of decay. This is an important self-applied source of fluorides, since about 90% of dentifrices sold contain fluoride Older clinical trials (coronal caries) and one recent trial (root caries) [57,59] (I) Everyone should use a fluoride dentifrice daily as part of regular oral hygiene; care should be taken, and supervision of toothpaste use by young children is required, to prevent swallowing of excess toothpaste (A)

Daily plaque removal by toothbrushing and flossing++ Although daily toothbrushing and flossing do not prevent caries, they are part of good oral hygiene and help to control gingival disease Professional opinion and descriptive studies [23,67] (III)
Evidence is from studies involving only very young children [67] (II-1)
Poor evidence to recommend this manoeuvre strictly for caries prevention; however, toothbrushing is essential for self-application of a fluoride dentifrice, which is a grade A recommendation (C)

Prophylaxis (cleaning) during periodic dental examinations++ Traditional dental prophylaxis is not effective in preventing caries, but it may be used to remove stain or calculus. Daily personal oral hygiene (toothbrushing and flossing) may prevent staining and calculus build-up RCTs, some of which included the use of fluoride pastes [67] (I) Poor evidence to include prophylaxis in recall dental visits strictly to prevent caries, but it may be recommended for individual patients on other grounds (II-2)

Fissure sealants Decay of pit-and-fissure surfaces is significantly statistically and clinically reduced if such sealants are used selectively RCTs [7,63,64] (I) Good evidence for selective use on permanent molars within 3 years of eruption in children at high risk of caries (A)

Counselling patients to reduce intake of cariogenic foods Despite early evidence, recent data suggest that dietary sugars do not have a major effect on the incidence of caries One trial involving patients in an institution (II-1). Recent cohort studies [28,29,66] (II-2) Poor evidence of effectiveness of changes in diet for the general population and of the effectiveness of dental counselling in inducing changes in diet; however, counselling is recommended for patients at a high risk of caries (C)

Counselling patients to reduce nocturnal and long-term feeding with baby bottles containing liquids other than water Bottle feeding with sugary liquids for long periods is the main cause of nursing caries; however, the effectiveness of counselling patients to change this practice has not been evaluated Case-control studies [35,36] (II-2) Counselling patients to change infant-feeding practices to prevent caries is recommended (C)

*For descriptions of levels of evidence and classification of recommendations see Appendix 1 in part 1 of the 1992 update (CMAJ 1992; 147: 443).
+The recommendations for the use of this manoeuvre in the general population and in groups at high risk differ. Despite older randomized controlled trials supporting the use of this manoeuvre, routine use for the general population is now problematic as a result of the decline in the incidence of caries.
++Effectiveness, evidence and recommendations for this manoeuvre refer to prevention of dental caries only; the evidence and recommendations concerning prevention of periodontal disease may be different.

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Table 3: Summary of manoeuvres, effectiveness, levels of evidence and recommendations for the prevention of dental caries
Manoeuvre	Effectiveness	Level of evidence*	Recommendation*
Drinking-water fluoridation (1.0-1.2 ppm)	Reductions in the incidence of dental caries of 20% to 40% have been reported	Prevention of coronal caries; well-designed and controlled community trials without randomization [19,48] (II-1)	Good evidence that water fluoridation is the most effective, equitable and efficient preventative for coronal and root dental caries (A)
Daily fluoride supplementation (only where fluoride levels in drinking water are 0.3 ppm or less)	Reductions in the incidence of caries in children similar to those achieved by drinking-water fluoridation have been reported; however, parent compliance in providing children with daily supplements is poor	Nonrandomized controlled trials [51,56] (II-1). The new lower dosage schedule approved by the Canadian Dental Association has not been subjected to clinical trials	Good evidence of reductions in the incidence of decay if the proper dosage schedule is carefully followed; however, inappropriate prescribing of excess fluoride supplements is the main factor in recent increases in the incidence of fluorosis (A)
Annual or biannual professional application of topical fluorides such as acidulated phosphate fluoride gel+	This is a labour-intensive and expensive procedure that is not effective and efficient for most patients in communities with fluoridated or nonfluoridated drinking water. It is effective if used selectively	Prevention of coronal caries: randomized controlled trials (RCTs) involving mainly children and adolescents and conducted before the incidence of caries had declined [57] (I) Prevention of root caries and excess caries resulting from reduced salivary flow caused by radiation therapy or chemotherapy: professional opinion [57] (III)	Good evidence to support this procedure for those with very active decay or at a high risk of caries, since caries in these groups mimic that in the general population before the incidence of caries had declined (A) Poor evidence to include this procedure in periodic dental examinations for the general population, but it may be recommended for individual patients on other grounds (C)

Prophylaxis (cleaning) before professional application of a topical fluoride	Study results show that the incidence of dental caries is equivalent with or without prophylaxis	RCTs [21,57] (I)	Good evidence to recommend that such prophylaxis be excluded from periodic dental examinations (E)
Use of fluoride mouth rinses (containing 0.20% sodium fluoride, weekly, or 0.05% sodium fluoride, daily)	Statistically and clinically significant reductions in the incidence of caries were previously reported; however, in an era if declining incidence, the effectiveness of this procedure for most children is questionable	Older, randomized trials involving schoolchildren and more recent trials [57,62] (I) Recent over-the-counter fluoride mouth rinses for home use have not been well evaluated [60] (III)	Good evidence for use of this manoeuvre for those with very active decay or a high risk of caries (A) Poor evidence to recommend this manoeuvre for the general population, but it may be recommended for individual patients on other grounds Good evidence to recommend against the home use of over-the-counter fluoride mouth rinses for the general population (E)
Use of self-applied fluoride dentifrices+	Daily use results in statistically significant reductions in the incidence of decay. This is an important self-applied source of fluorides, since about 90% of dentifrices sold contain fluoride	Older clinical trials (coronal caries) and one recent trial (root caries) [57,59] (I)	Everyone should use a fluoride dentifrice daily as part of regular oral hygiene; care should be taken, and supervision of toothpaste use by young children is required, to prevent swallowing of excess toothpaste (A)
Daily plaque removal by toothbrushing and flossing++	Although daily toothbrushing and flossing do not prevent caries, they are part of good oral hygiene and help to control gingival disease	Professional opinion and descriptive studies [23,67] (III) Evidence is from studies involving only very young children [67] (II-1)	Poor evidence to recommend this manoeuvre strictly for caries prevention; however, toothbrushing is essential for self-application of a fluoride dentifrice, which is a grade A recommendation (C)
Prophylaxis (cleaning) during periodic dental examinations++	Traditional dental prophylaxis is not effective in preventing caries, but it may be used to remove stain or calculus. Daily personal oral hygiene (toothbrushing and flossing) may prevent staining and calculus build-up	RCTs, some of which included the use of fluoride pastes [67] (I)	Poor evidence to include prophylaxis in recall dental visits strictly to prevent caries, but it may be recommended for individual patients on other grounds (II-2)
Fissure sealants	Decay of pit-and-fissure surfaces is significantly statistically and clinically reduced if such sealants are used selectively	RCTs [7,63,64] (I)	Good evidence for selective use on permanent molars within 3 years of eruption in children at high risk of caries (A)
Counselling patients to reduce intake of cariogenic foods	Despite early evidence, recent data suggest that dietary sugars do not have a major effect on the incidence of caries	One trial involving patients in an institution (II-1). Recent cohort studies [28,29,66] (II-2)	Poor evidence of effectiveness of changes in diet for the general population and of the effectiveness of dental counselling in inducing changes in diet; however, counselling is recommended for patients at a high risk of caries (C)
Counselling patients to reduce nocturnal and long-term feeding with baby bottles containing liquids other than water	Bottle feeding with sugary liquids for long periods is the main cause of nursing caries; however, the effectiveness of counselling patients to change this practice has not been evaluated	Case-control studies [35,36] (II-2)	Counselling patients to change infant-feeding practices to prevent caries is recommended (C)