International Journal of Paediatric Dentistry 1992; 2: 145-1 49.
Effect of supervised use of a fluoride toothpaste on caries incidence in pre-school children P. H d L T T A & S. A L A L U U S U A Department of Pedodontics and Orthodontics, University of Helsinki
Summary. Caries prevalence of children living in Helsinki is low and little further reduction has been seen during recent years. The aim of the study was to investigate whether a supervised daily brushing at school with a fluoride toothpaste containing 1.2% sodium monofluorophosphate reduced caries incidence in a well-controlled group of nursery-school children with low caries prevalence. A total of 87 children from two nursery schools formed the test group. Agroup ofchildren matched for age, baseline dfs and follow-up time, who had attended the same nursery schoolsjust before starting this prospective study and who had brushed their teeth daily at school without toothpaste, formed a retrospective control group. After the follow-up time (mean 1.4 years), the total number of new carious surfaces was 2 3 in the test group (mean 0 - 3 ) and 8 3 in the control group (mean 0-9); the difference was significant. In the test group 72% and in the control group 62% of children were caries-freeafter the follow-upperiod. The results suggest that the use of a fluoride toothpaste as an extra daily prophylaxis reduces caries incidence in pre-school children.
Introduction Caries prevalence in pre-school children living in Helsinki, the capital of Finland, is low; about 90% of 3-year-olds were caries-free in 1989 [I]. However, even if the mean caries prevalence is low, there is a small proportion of children whose caries prevalence is high. Since it is difficult at an early age to identify individuals who have a high caries risk [2,3], caries prevention should cover all young children. In Finland, fluoride tablets are recommended in non-fluoridated communities, such as Helsinki, for every child from the age of 6 months. Fluoride toothpaste has not been recommended for children under the age of 5 years, because it has been thought that the dosage of fluoride is better controlled through a tablet regime. According to a large survey of health services research by the National Board of Health in Finland [4], only Correspondence and reprint requests to: Dr Paivi Holtta, Department of Pedodontics and Orthodontics, Institute of Dentistry, University of Helsinki, Mannerheimintie 172, 00300 Helsinki, Finland.
about half of the 2 to 6-year-olds used fluoride at home from one source (tablets or toothpaste), while one third did not get fluoride from any source. Thus a need was identified for an extra prophylactic programme that would reach the children whose parents often overlook their dental care. The aim of the present study was to investigate whether a supervised brushing of teeth 5 days a week with a fluoride toothpaste in nursery schools reduced caries incidence in pre-school children.
Methods The test group for the study, starting from September 1988, comprised all the children (n=135) attending two nursery schools located in the vicinity of the Institute of Dentistry, University of Helsinki. These children were to brush their teeth daily with a toothpaste containing 1.2% sodium monofluorophosphate under supervision at their schools. The parents were sent written informa145
146
P. Holtta & S. Alaluusua
tion about the use of fluoride toothpaste. Neither the parents nor the staff of the nursery schools were informed of the study. The control group comprised all the children ( n = 143) who had attended the same two schools from January 1986 to August 1988; thus, it was a retrospective control group. These children had brushed their teeth daily with a toothbrush but no toothpaste under supervision at their schools. Children from both schools came from the same residential area of average income families. The catchment areas of the nursery schools remained the same and there was no new housing in this part of the city during the study period. All children attended the Department of Pedodontics and Orthodontics, Institute of Dentistry, for their regular dental care. All children who receive dental care in the department are examined once a year, receive oral hygiene instruction and application of fluoride varnish, and are given further appointments if necessary. Individual counselling is given also to the parents during the visits about fluorides, diet and hygiene. The baseline data for the test and control group children in the study were obtained from dental records in September 1988 and January 1986, respectively. All examinations of the children were carried out by two dentists who had over 10 years’ experience as instructors in the Department of Pedodontics and Orthodontics, University of Helsinki and who were not aware of the study protocol; they examined the children as part of their normal work. They used a plane mouth mirror, a probe, and a fibre optic light source. If caries was suspected in one or more surfaces of the molar teeth, or if a child had previous carious lesions, bitewing radiographs were taken. Caries was recorded as present when a lesion in a pit or fissure, or on a smooth tooth surface, had a softened floor, undermined enamel or softened wall [5], or when in the radiograph there was a carious lesion with a distinct extension into the dentine [6]. If permanent teeth erupted during the follow-up period, they were included in the study. No teeth were extracted before or during the study. Daily toothbrushing with a brush but no toothpaste has been supervised by nursery school staff for several years. Daily brushing with the fluoride toothpaste started in September, 1988. The staff of the nursery schools were advised to restrict the amount of paste to the size of a pea(not more than
0.5 mg F) and to tell the children not to swallow it, but otherwise to supervise the children as before. The statistical analysis was performed by means of the Chi-squared test.
Results From the original test group (n= 135) 44 children were excluded because they had attended the nursery school for less than a year, two because of medical reasons, and two because they obtained regular dental care elsewhere. Therefore, 87 children formed the final test group. Every child was followed up for at least one year (mean 1.4 yrs) if they had attended the nursery school continuously and their complete dental records were available. Table 1. Age and sex of the test and control group children
Sex (number) Boys Girls
Test group
Control group
4.5 3.0-6.3
4.5 3.0-6.3
41 46
40 47
From the original control group (n= 143) children were excluded by the same criteria. As a result 96 children remained and nine of them, who could not be matched with the children in the test group by the same age, follow-up time and baseline dfs, were excluded. The remaining 87 children formed the control group. Table 1 presents details of the test and control groups. The data in Table 2 show that the total number of new carious surfaces was 23 in the test group and 83 in the control group. The mean caries increment was 0.3 in the test group and 0-9 in the control group; the difference was significant k 2 = 9 - 7 4 , Pt0-05). The mean caries increment of the boys in the test group was significantly less than that in control group k 2 = 7 - 8 9 , Pt0.05), but among the girls the difference was not significant k2=4.77, E-0.05). The difference in final d ! + D F S between the test and the control groups (mean dfs+DFS-values 1.3 and 2.0, respectively)
Fluoride toothpaste and caries incidence in pre-school children
147
Table 2. Caries increments (mean fSD) in the test and control groups Control group
Test group Boys (n=46)
Girls (n=41)
Total (n=87)
Boys (n=47)
Girls (n=40)
Total (n=87)
~~
dfsS DFS Start End Increment
1 . 1 k 3 . 0 1.Ok2.7 1.Ok2.8 1.2k3.0 1.4f3.1 1.3k3.0 0.1 k 0 . 3 7 0 . 4 + 1.1 0 . 3 k 0 . 9 *
Number of caries-free children Start End
33 30
1.2k3.0 0.9k2.5 2.1 k 4 . 0 1.9k3.8 1 . 0 k 2 . 0 t 0 . 9 + 1.9
69 63*
36 33
31 23
1.0k2.7 2.0k3.9 0 . 9 f 1.9.
38 31
69 54*
*Difference between test and control groups significant, P t 0 . 0 5 . ?Difference between boys in test and control groups significant, PtO.05.
Table 3. Number of new carious surfaces (dfs-t DFS) in the test and control groups Test group Tooth surfaces Occlusal Buccal and lingual Approximal Total dfs+ DFS
Control group
Boys (n=46)
Girls (n=41)
Total (N=87)
Boys (n=47)
Girls (n=40)
Total (n=87)
2tt 2ttt
7 0 12$$$
9 0** 14***
13tt 5t 2lttt
5 3 36$$$
18 8** 57***
4t
19
2 3%
39t
44
83*
ot
Significance of differences between test and control groups: *Pt0.05, **Pt0.01, ***PtO.OOl. Significance of differences between boys in test and control groups: tPtO.05, t t P t 0 . 0 1 ,
tttP
Effect of supervised use of a fluoride toothpaste on caries incidence in pre-school children P. H d L T T A & S. A L A L U U S U A Department of Pedodontics and Orthodontics, University of Helsinki
Summary. Caries prevalence of children living in Helsinki is low and little further reduction has been seen during recent years. The aim of the study was to investigate whether a supervised daily brushing at school with a fluoride toothpaste containing 1.2% sodium monofluorophosphate reduced caries incidence in a well-controlled group of nursery-school children with low caries prevalence. A total of 87 children from two nursery schools formed the test group. Agroup ofchildren matched for age, baseline dfs and follow-up time, who had attended the same nursery schoolsjust before starting this prospective study and who had brushed their teeth daily at school without toothpaste, formed a retrospective control group. After the follow-up time (mean 1.4 years), the total number of new carious surfaces was 2 3 in the test group (mean 0 - 3 ) and 8 3 in the control group (mean 0-9); the difference was significant. In the test group 72% and in the control group 62% of children were caries-freeafter the follow-upperiod. The results suggest that the use of a fluoride toothpaste as an extra daily prophylaxis reduces caries incidence in pre-school children.
Introduction Caries prevalence in pre-school children living in Helsinki, the capital of Finland, is low; about 90% of 3-year-olds were caries-free in 1989 [I]. However, even if the mean caries prevalence is low, there is a small proportion of children whose caries prevalence is high. Since it is difficult at an early age to identify individuals who have a high caries risk [2,3], caries prevention should cover all young children. In Finland, fluoride tablets are recommended in non-fluoridated communities, such as Helsinki, for every child from the age of 6 months. Fluoride toothpaste has not been recommended for children under the age of 5 years, because it has been thought that the dosage of fluoride is better controlled through a tablet regime. According to a large survey of health services research by the National Board of Health in Finland [4], only Correspondence and reprint requests to: Dr Paivi Holtta, Department of Pedodontics and Orthodontics, Institute of Dentistry, University of Helsinki, Mannerheimintie 172, 00300 Helsinki, Finland.
about half of the 2 to 6-year-olds used fluoride at home from one source (tablets or toothpaste), while one third did not get fluoride from any source. Thus a need was identified for an extra prophylactic programme that would reach the children whose parents often overlook their dental care. The aim of the present study was to investigate whether a supervised brushing of teeth 5 days a week with a fluoride toothpaste in nursery schools reduced caries incidence in pre-school children.
Methods The test group for the study, starting from September 1988, comprised all the children (n=135) attending two nursery schools located in the vicinity of the Institute of Dentistry, University of Helsinki. These children were to brush their teeth daily with a toothpaste containing 1.2% sodium monofluorophosphate under supervision at their schools. The parents were sent written informa145
146
P. Holtta & S. Alaluusua
tion about the use of fluoride toothpaste. Neither the parents nor the staff of the nursery schools were informed of the study. The control group comprised all the children ( n = 143) who had attended the same two schools from January 1986 to August 1988; thus, it was a retrospective control group. These children had brushed their teeth daily with a toothbrush but no toothpaste under supervision at their schools. Children from both schools came from the same residential area of average income families. The catchment areas of the nursery schools remained the same and there was no new housing in this part of the city during the study period. All children attended the Department of Pedodontics and Orthodontics, Institute of Dentistry, for their regular dental care. All children who receive dental care in the department are examined once a year, receive oral hygiene instruction and application of fluoride varnish, and are given further appointments if necessary. Individual counselling is given also to the parents during the visits about fluorides, diet and hygiene. The baseline data for the test and control group children in the study were obtained from dental records in September 1988 and January 1986, respectively. All examinations of the children were carried out by two dentists who had over 10 years’ experience as instructors in the Department of Pedodontics and Orthodontics, University of Helsinki and who were not aware of the study protocol; they examined the children as part of their normal work. They used a plane mouth mirror, a probe, and a fibre optic light source. If caries was suspected in one or more surfaces of the molar teeth, or if a child had previous carious lesions, bitewing radiographs were taken. Caries was recorded as present when a lesion in a pit or fissure, or on a smooth tooth surface, had a softened floor, undermined enamel or softened wall [5], or when in the radiograph there was a carious lesion with a distinct extension into the dentine [6]. If permanent teeth erupted during the follow-up period, they were included in the study. No teeth were extracted before or during the study. Daily toothbrushing with a brush but no toothpaste has been supervised by nursery school staff for several years. Daily brushing with the fluoride toothpaste started in September, 1988. The staff of the nursery schools were advised to restrict the amount of paste to the size of a pea(not more than
0.5 mg F) and to tell the children not to swallow it, but otherwise to supervise the children as before. The statistical analysis was performed by means of the Chi-squared test.
Results From the original test group (n= 135) 44 children were excluded because they had attended the nursery school for less than a year, two because of medical reasons, and two because they obtained regular dental care elsewhere. Therefore, 87 children formed the final test group. Every child was followed up for at least one year (mean 1.4 yrs) if they had attended the nursery school continuously and their complete dental records were available. Table 1. Age and sex of the test and control group children
Sex (number) Boys Girls
Test group
Control group
4.5 3.0-6.3
4.5 3.0-6.3
41 46
40 47
From the original control group (n= 143) children were excluded by the same criteria. As a result 96 children remained and nine of them, who could not be matched with the children in the test group by the same age, follow-up time and baseline dfs, were excluded. The remaining 87 children formed the control group. Table 1 presents details of the test and control groups. The data in Table 2 show that the total number of new carious surfaces was 23 in the test group and 83 in the control group. The mean caries increment was 0.3 in the test group and 0-9 in the control group; the difference was significant k 2 = 9 - 7 4 , Pt0-05). The mean caries increment of the boys in the test group was significantly less than that in control group k 2 = 7 - 8 9 , Pt0.05), but among the girls the difference was not significant k2=4.77, E-0.05). The difference in final d ! + D F S between the test and the control groups (mean dfs+DFS-values 1.3 and 2.0, respectively)
Fluoride toothpaste and caries incidence in pre-school children
147
Table 2. Caries increments (mean fSD) in the test and control groups Control group
Test group Boys (n=46)
Girls (n=41)
Total (n=87)
Boys (n=47)
Girls (n=40)
Total (n=87)
~~
dfsS DFS Start End Increment
1 . 1 k 3 . 0 1.Ok2.7 1.Ok2.8 1.2k3.0 1.4f3.1 1.3k3.0 0.1 k 0 . 3 7 0 . 4 + 1.1 0 . 3 k 0 . 9 *
Number of caries-free children Start End
33 30
1.2k3.0 0.9k2.5 2.1 k 4 . 0 1.9k3.8 1 . 0 k 2 . 0 t 0 . 9 + 1.9
69 63*
36 33
31 23
1.0k2.7 2.0k3.9 0 . 9 f 1.9.
38 31
69 54*
*Difference between test and control groups significant, P t 0 . 0 5 . ?Difference between boys in test and control groups significant, PtO.05.
Table 3. Number of new carious surfaces (dfs-t DFS) in the test and control groups Test group Tooth surfaces Occlusal Buccal and lingual Approximal Total dfs+ DFS
Control group
Boys (n=46)
Girls (n=41)
Total (N=87)
Boys (n=47)
Girls (n=40)
Total (n=87)
2tt 2ttt
7 0 12$$$
9 0** 14***
13tt 5t 2lttt
5 3 36$$$
18 8** 57***
4t
19
2 3%
39t
44
83*
ot
Significance of differences between test and control groups: *Pt0.05, **Pt0.01, ***PtO.OOl. Significance of differences between boys in test and control groups: tPtO.05, t t P t 0 . 0 1 ,
tttP
