SCIENTIFIC FEATURE Fluoride: The Silver Bullet in Preventive Dentistry

Abstract

Fluorides have long been recognized for their effectiveness in reducing the incidence and severity of dental caries, making them a cornerstone of modern preventive dentistry. However, clinicians and practitioners might face certain dilemmas around the use of fluorides, some of which are the effectiveness of systemic or topical fluoride, the use of monotherapy versus combination fluoride therapy, or whether to use fluoride supplements for their patients. Furthermore, there have been concerns about the oral and systemic toxicity and adverse effects of fluorides. The purpose of this paper is to delve into the world of fluoride treatment, with a specific emphasis on evidence-based recommendations, most of which are pivoted on high-quality systematic reviews or clinical trials. By centering our discussion on evidence-based practices, this paper seeks to assist dental professionals, policymakers, and the public in making informed decisions regarding some of the dilemmas faced during fluoride administration.

Introduction

Fluoride therapy has remained a cornerstone of preventive dentistry, aimed at maintaining and enhancing oral health by strengthening tooth enamel and reducing the risk of dental decay. It inhibits demineralization by forming a fluoride reservoir on the tooth surface, which is not readily soluble and more resistant to acid dissolution. It also enhances the remineralization of the tooth enamel. As one of the most effective and cost-efficient methods in dentistry, fluoride treatment is crucial in promoting oral hygiene and preserving healthy smiles for individuals of all ages. This paper aims to delve into the world of fluoride treatment, with a specific emphasis on evidence-based recommendations, most of which are pivoted on high-quality systematic reviews or clinical trials. By centering our discussion on evidence-based practices, this paper seeks to assist dental professionals, policymakers, and the public in making informed decisions regarding some of the dilemmas faced during the administration of fluoride. Ultimately, the goal is to underscore the crucial role that fluoride plays in oral health while ensuring that its application aligns with the highest standards of scientific rigor and patient well-being.

ARE SYSTEMIC FLUORIDES REALLY EFFECTIVE IN PREVENTING DENTAL CARIES?

The question of whether fluoride is truly effective in preventing dental caries has been a subject of considerable debate and investigation within the field of dentistry. Community water fluoridation is one of the oldest methods to administer systemic fluoride and is considered a cost-effective and accessible strategy to prevent dental caries. A systematic review pooling 155 studies concluded that although the “initiation of water fluoridation” caused lower dmft (decayed, missing, or filled teeth) scores in deciduous dentition or DMFT in permanent dentition, the quality of evidence was low [1]. Similarly, the proportion of caries-free children with deciduous and permanent teeth increased with water fluoridation, but the evidence was low. Contrary to “initiation of water fluoridation”, there was no evidence to determine whether “cessation of water fluoridation” affected caries in deciduous dentition or the proportion of caries-free children in deciduous or permanent dentition. Also, nearly all the included studies were conducted prior to 1975 and were observational with a high risk of bias, raising concerns on the internal validity of the results. However, recent data from the National Health and Nutrition Examination Survey (NHANES) concluded that water fluoridation might result in 1.3 fewer dfs (decayed or filled surfaces) per child or 0.3 fewer DMFS (decayed, missing, or filled surfaces) per child, which might appear to be small or have negligible effect, but when translated clinically to the whole population of children in the US, will result in millions of less carious teeth surfaces [2]. However, the challenge to water fluoridation might be the lack of water fluoridation, rising use of bottled water, and public opposition to water fluoridation. [3]

Fluoridated milk has been another modality that has been tried to ward off dental caries; however, the data is limited. The Cochrane review published in 2015 only reported on one randomized clinical trial involving 166 participants. Although mean caries in the primary and permanent teeth were low in the milk fluoridation group, the certainty of evidence was too low to generate any robust conclusion [4]. Fluoride has been tried in other foods as well, like salt and sugar, with an intention to provide systemic effect and prevent dental caries; however, the evidence of the effectiveness of fluorides added in salt or sugar is scant due to no or very few studies [5,6]. Thus, this might be a future research area for those studying food fortification for better health outcomes.

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