Levels of evidence (Ia-IV) and grades of recommendation (A-D) are defined at the end of the "Major Recommendations" field.
The panel encourages dentists to employ caries risk assessment strategies in their practices. Appropriate preventive dental treatment (including topical fluoride therapy) can be planned after identification of caries risk status (see table below). It also is important to consider that risk of developing dental caries exists on a continuum and changes over time as risk factors change. Therefore, caries risk status should be re-evaluated periodically.
| Table: Caries Risk Criteria |
|
Patients should be evaluated using caries risk criteria such as those below.
LOW CARIES RISK
All age groups
No incipient or cavitated primary or secondary carious lesions during the last three years and no factors that may increase caries risk*
MODERATE CARIES RISK
Younger than 6 years
No incipient or cavitated primary or secondary carious lesions during the last three years but presence of at least one factor that may increase caries risk*
Older than 6 years (any of the following)
- One or two incipient or cavitated primary or secondary carious lesions in the last three years
- No incipient or cavitated primary or secondary carious lesions in the last three years but presence of at least one factor that may increase caries risk*
HIGH CARIES RISK
Younger than 6 years (any of the following)
- Any incipient or cavitated primary or secondary carious lesion during the last three years
- Presence of multiple factors that may increase caries risk*
- Low socioeconomic status**
- Suboptimal fluoride exposure
- Xerostomia***
Older than 6 years (any of the following)
- Three or more incipient or cavitated primary or secondary carious lesions in the last three years
- Presence of multiple factors that may increase caries risk*
- Suboptimal fluoride exposure
- Xerostomia***
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* Factors increasing risk of developing caries also may include, but are not limited to, high titers of cariogenic bacteria, poor oral hygiene, prolonged nursing (bottle or breast), poor family dental health, developmental or acquired enamel defects, genetic abnormality of teeth, many multisurface restorations, chemotherapy or radiation therapy, eating disorders, drug or alcohol abuse, irregular dental care, cariogenic diet, active orthodontic treatment, presence of exposed root surfaces, restoration overhangs and open margins, and physical or mental disability with inability or unavailability of performing proper oral health care.
** On the basis of findings from population studies, groups with low socioeconomic status have been found to have an increased risk of developing caries. In children too young for their risk to be based on caries history, low socioeconomic status should be considered as a caries risk factor.
*** Medication-, radiation- or disease-induced xerostomia.
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The table below summarizes the evidence-based clinical recommendations for the use of professionally applied topical fluoride. The clinical recommendations are a resource for dentists to use. These clinical recommendations must be balanced with the practitioner's professional judgment and the individual patient's preferences.
It is recommended that all age and risk groups use an appropriate amount of fluoride toothpaste when brushing twice a day, and that the amount of toothpaste used for children younger than 6 years not exceed the size of a pea. For patients at moderate and high risk of caries, additional preventive interventions should be considered, including use of additional fluoride products at home, pit-and-fissure sealants, and antibacterial therapy.
| Table: Evidence-based Clinical Recommendations for Professionally Applied Topical Fluoride |
| Risk Category |
AGE CATEGORY FOR RECALL PATIENTS |
| |
< 6 Years |
| Recommendation |
Grade of Evidence |
Strength of Recommendation |
| Low |
May not receive additional benefit from professional topical fluoride application* |
Ia |
B |
| Moderate |
Varnish application at 6-month intervals |
Ia |
A |
| High |
Varnish application at 6-month intervals |
Ia |
A |
| OR |
|
|
| Varnish application at 3-month intervals |
Ia |
D** |
| |
6 to 18 Years |
| |
Recommendation |
Grade of Evidence |
Strength of Recommendation |
| Low |
May not receive additional benefit from professional topical fluoride application* |
Ia |
B |
| Moderate |
Varnish application at 6-month intervals |
Ia |
A |
| OR |
|
|
| Fluoride gel application at 6-month intervals |
Ia |
A |
| High |
Varnish application at 6-month intervals |
Ia |
A |
| OR |
|
|
| Varnish application at 3-month intervals |
Ia |
A** |
| OR |
|
|
| Fluoride gel application at 6-month intervals |
Ia |
A |
| OR |
|
|
| Fluoride gel application at 3-month intervals |
IV |
D*** |
| |
18 + Years |
| |
Recommendation |
Grade of Evidence |
Strength of Recommendation |
| Low |
May not receive additional benefit from professional topical fluoride application* |
IV |
D |
| Moderate |
Varnish application at 6-month intervals |
IV |
D# |
| OR |
|
|
| Fluoride gel application at 6-month intervals |
IV |
D*** |
| High |
Varnish application at 6-month intervals |
IV |
D# |
| OR |
|
|
| Varnish application at 3-month intervals |
IV |
D# |
| OR |
|
|
| Fluoride gel application at 6-month intervals |
IV |
D*** |
| OR |
|
|
| Fluoride gel application at 3-month intervals |
IV |
D*** |
|
* Fluoridated water and fluoride toothpastes may provide adequate caries prevention in this risk category. Whether or not to apply topical fluoride in such cases is a decision that should balance this consideration with the practitioner's professional judgment and the individual patient's preferences.
** Emerging evidence indicates that applications more frequent than twice per year may be more effective in preventing caries.
*** Although there are no clinical trials, there is reason to believe that fluoride gels would work similarly in this age group.
# Although there are no clinical trials, there is reason to believe that fluoride varnish would work similarly in this age group.
Laboratory data demonstrate foam's equivalence to gels in terms of fluoride release; however, only two clinical trials have been published evaluating its effectiveness. Because of this, the recommendations for use of fluoride varnish and gel have not been extrapolated to foams.
Because there is insufficient evidence to address whether or not there is a difference in the efficacy of sodium fluoride versus acidulated phosphate fluoride gels, the clinical recommendations do not specify between these two formulations of fluoride gels. Application time for fluoride gel and foam should be four minutes. A one-minute fluoride application is not endorsed.
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Definitions:
Levels of Evidence
Ia Evidence from systematic reviews of randomized controlled trials
Ib Evidence from at least one randomized controlled trial
IIa Evidence from at least one controlled study without randomization
IIb Evidence from at least one other type of quasi-experimental study
III Evidence from nonexperimental descriptive studies, such as comparative studies, correlation studies, cohort studies and case-control studies
IV Evidence from expert committee reports or opinions or clinical experience of respected authorities
* Amended with permission of the BMJ Publishing Group from Shekelle and colleagues. (Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Clinical guidelines: developing guidelines. Brit Med J 1999;318(7183):593-6.
Grading of Recommendations
A Directly based on category I evidence
B Directly based on category II evidence or extrapolated recommendation from category I evidence
C Directly based on category III evidence or extrapolated recommendation from category I or II evidence
D Directly based on category IV evidence or extrapolated recommendation from category I, II or III evidence
* Amended with permission of the BMJ Publishing Group from Shekelle and colleagues. (Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Clinical guidelines: developing guidelines. Brit Med J 1999;318(7183):593-6.
