Brodam W. Cochrane-review: Fluor fra tandpasta er tilstrækkeligt

Administration af ekstra fluor (ud over den fra tandpasta), i form af fx skyllemidler, gel eller lak, reducerer cariesudviklingen yderligere, men ekstragevinsten er ikke stor.

Sådan lyder konklusionen på et af Cochranes nyligt opdaterede reviews. Det pågældende review fandt ingen negative effekter af eventuel ekstra fluoradministration.

11 studier indgår i Cochranes metaanalyse – af dem omhandler de ni effekten af skyllemidler med fluor, geler eller lak med fluor i kombination med fluortandpasta.

Kommentar af lektor Kim Ekstrand, Afdeling for Cariologi og Endodonti, Tandlægeskolen i København:
- Reviewets konklusioner er ikke nye. Eksempelvis viste SBUrapporten fra 2002, »Att förebygga karies«, at der ikke var megen cariesreduktion at hente ved fx at skylle med mundskyllevæske med fluor på børn og unge, som samtidig brugte fluortandpasta. Baggrundsundersøgelserne i det aktuelle review og i SBU-rapporten er stort set de samme, og den overordnede konklusion er, at fluortandpasta er fundamentet i kontrol af cariessygdommen.

SBU-rapporten viste endvidere, at øges ppm-mængden af fluor i tandpastaen med 500 ppm fx fra 1.000 til 1.500 ppm, resulterer det i en ca. 8 %’s reduktion i DMFS. Det forhold kan bruges aktivt i indsatsen mod caries, når fluor bruges efter devisen: maksimal effekt på caries – minimale bivirkninger.

I overensstemmelse med internationale anbefalinger, og formodentlig også med reviewforfatternes, anbefaler Afdeling for Cariologi og Endodonti, Tandlægeskolen i København, brug af 1.100 ppm fluortandpasta i dentalal-dre, fra 1. tand bryder frem, til approksimal kontakt er etableret mellem 04/05 (ca. 3½ år). I de ca. 10 kommuner i landet, hvor fluoridkoncentrationen i drikkevandet er > 0,9 ppm, kan anbefales tandpasta med eksempelvis 500 ppm fluorid. Fra 3½-års-alderen og frem anbefales brugen af 1.450 ppm fluortandpasta, specielt under frembrudsfaserne af 1.- og
2.-molarer. Mængden af tandpasta fra ottemånedersalderen til ca. otte år må ikke overskride størrelsen af barnets lillefingernegl pr. dag – det er koncentrationen af fluorid, der er vigtig – ikke mængden af tandpasta (Ellwood & Fejerskov, 2003).

Supplementer som skyllevæsker med fluor, geler, lokale applikationer med 2 % NaF eller Duraphat etc. bør bruges ved høj cariesrisiko og/eller på direkte diagnose: caries dentalis progressiva superficialis. Som det ser ud nu, er fluorid ikke virksomt ved
erosioner.

Litteratur
SBU-rapporten »Att förebygga karies« – Statens beredning för medicinsk utvärdering, 2002, www.sbu.se, rapport 161.

Ellwood R, Fejerskov O. Clinical use of fluoride. In: Fejerskov O, Kidd E, editors. Dental caries, the disease and its clinical management. Copenhagen: Blackwell/Munksgaard; 2003.

Abstract

Background
Topical fluoride therapy (TFT) in the form of toothpastes, mouthrinses, varnishes and gels are effective caries preventive measures.

However, there is uncertainty about the relative value of these interventions when used together.

Objectives
To compare the effectiveness of two TFT modalities combined with one of them alone (mainly toothpaste) when used for the prevention of dental caries in children.

Search strategy
We searched the Cochrane Oral Health Group’s Trials Register (May 2000), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2000), MEDLINE (1966 to January 2000), plus several other databases. We handsearched journals, reference lists of articles and contacted selected authors and manufacturers.

Selection criteria
Randomized or quasi-randomized controlled trials with blind outcome assessment, comparing fluoride varnish, gel, mouthrinse, or toothpaste in combination with each other in children up to 16 years during at least 1 year. The main outcome was caries increment measured by the change in decayed, missing and filled tooth surfaces (D(M)FS).

Data collection and analysis
Inclusion decisions, quality assessment and data extraction were duplicated in a random sample of one third of studies, and consensus achieved by discussion or a third party. Authors were contacted for missing data. The primary measure of effect
was the prevented fraction (PF) that is the difference in mean caries increments between the »treatment« and »control« groups expressed as a percentage of the mean increment in the control group. Random effects meta-analyses were performed where data could be pooled.

Main results
Eleven of the 12 included studies contributed data for the meta-analyses. For the nine trials that provided data for the main meta-analysis on the effect of fluoride mouthrinses, gels or varnishes used in combination with toothpaste (involving 4026
children) the D(M)FS pooled PF was 10 % (95 % CI, 2 % to 17 %; p = 0.01) in favour of the combined regimens. Heterogeneity was not substantial in these results (I square = 32 %). The separate meta-analyses of fluoride gel or mouthrinse combined
with toothpaste versus toothpaste alone favour the combined regimens, but differences were not statistically significant; the significant difference in favour of the combined use of fluoride varnish and toothpaste accrues from a very small trial and appears likely to be a spurious result. Not all other combinations of possible practical value were tested in the included studies. The only other statistically significant result was in favour of the combined use of fluoride gel and mouthrinse in comparison
to gel alone (pooled DMFS PF 23 %; 95 % CI, 4 % to 43 %; p = 0.02), based on two trials. No other combinations of TFT were consistently superior to a single TFT.

Authors’ conclusions
Topical fluorides (mouthrinses, gels, or varnishes) used in addition to fluoride toothpaste achieve a modest reduction in caries compared to toothpaste used alone. No conclusions about any adverse effects could be reached, because data were
scarcely reported in the trials.

Marinho VCC, Higgins JPT, Sheiham A, Logan S. Combinations of topical fluoride (toothpastes, mouthrinses, gels, varnishes) versus single topical fluoride for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No: CD002781.DOI:10.1002/14651858.CD002781.
pub2.