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Rinsing with Fluoride Toothpaste Slurry may Prevent Dental Caries in Orthodontic Patients
DIAGNOSIS/TREATMENT/PROGNOSIS
ARTICLE ANALYSIS & EVALUATION ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION Modified fluoride toothpaste technique reduces caries in orthodontic patients: a longitudinal, randomized clinical trial. Al Mulla AH, Kharsa SA, Birkhed D. Am J Orthod Dentofacial Orthop 2010;138(3):285-91.
REVIEWER Joana Cunha-Cruz, PhD
PURPOSE/QUESTION What is the caries incidence of orthodontic patients using a modified oral hygiene technique compared with orthodontic patients using routine oral hygiene technique?
SOURCE OF FUNDING Information not available
TYPE OF STUDY/DESIGN Randomized controlled trial
Rinsing with Fluoride Toothpaste Slurry may Prevent Dental Caries in Orthodontic Patients SUMMARY Subjects A total of 150 consecutive patients were recruited from a private orthodontic clinic in Riyadh, Saudi Arabia. Participants were quasi-randomly allocated to intervention (test) and control groups based on odd and even birth dates and followed until the end of treatment (2 years). Both baseline and final data analysis included 51 participants in the test group (68% of those originally allocated to intervention; 41 females, mean age 16.2 years) and 49 participants in the control group (65% of those originally allocated to control; 32 females, mean age 16.9 years).
Key Exposure/Study Factor Intervention: Modified toothbrushing technique —brushing teeth after breakfast and before bedtime with toothbrush and fluoride toothpaste for 2 minutes after spreading the toothpaste on the tooth surfaces and rinsing after brushing with toothpaste slurry for 30 seconds. At follow-up, 43% of the participants in the test group were considered to have very good compliance (reported compliance to 3 to 5 out of 5 instructions received) and the remaining were considered to have good compliance (reported compliance to 1 or 2 of the instructions received). Control: Routine oral hygiene instructions —brushing teeth after breakfast and before bedtime with toothbrush and fluoridated toothpaste and rinsing after brushing with fluoridated mouthwash. At follow-up, compliance was poor: 86% used only fluoridated toothpaste, 8% infrequently used fluoride mouthwash, and 6% used neither fluoridated toothpaste nor fluoride mouthwash.
LEVEL OF EVIDENCE Level 2
STRENGTH OF RECOMMENDATION GRADE
Main Outcome Measure Primary outcome —incidence of decayed and filled surfaces (DFS) based on clinical and radiographic examinations using the World Health Organization (WHO) criteria. Secondary outcomes —plaque index using Silness and Loe criteria.
Not applicable
Main Results The DFS incidence was 0.6 (SD = 2.1) for the test group and 3.5 (SD = 4.7) for the control group (P < .001). Prevented fraction was 83%. Plaque index at follow-up was 9.0 (SD = 8.0) for the test group and 11.6 (SD = 10) for the control group (P < .05).
Conclusions J Evid Base Dent Pract 2011;11:145-146 1532-3382/$36.00 Ó 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.jebdp.2011.06.003
The authors concluded that, compared with routine oral hygiene instructions with fluoride toothpaste, the use of a modified fluoride toothbrushing technique significantly reduced the incidence of new carious lesions in orthodontic patients.
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
COMMENTARY AND ANALYSIS Orthodontic patients are at greater risk of developing white spot lesions during orthodontic treatment.1- 4 Several advices and devices have been tested to prevent the development of new caries lesions during orthodontic treatment with questionable efficacy. The clinical trials on the effect of toothbrushing on preventing dental caries in orthodontic patients have mostly focused on types of toothbrushes and on surrogate outcomes such as white spot lesions, gingivitis, and dental plaque.5 The reviewed study proposed a simple modification of the toothbrushing technique commonly used by patients and observed a great benefit for orthodontic patients in preventing dental caries—a clinically relevant end point.6 The main differences of the proposed technique from routine oral hygiene were the spreading of the toothpaste on tooth surfaces before brushing and the rinsing with toothpaste slurry after brushing, instead of fluoride mouthwash. Even though we cannot disentangle which of the modified procedures contributed to the reduction in dental caries, as the authors pointed out, the simplicity of both technique modifications may warrant the use of the modified technique as standard oral hygiene instructions to orthodontic patients. The main limitations of the study were the possible presence of selection and ascertainment biases. The randomized clinical trial was not really random, which may have introduced selection bias. Participants were assigned to the groups by birth date, which is considered a quasirandom process. The treatment allocation then was not concealed, given that by knowing the prospective participant’s birth date one could foresee which treatment the patient would receive. Besides the study not being really random, balance in baseline outcome variables was achieved, for which descriptive statistics were similar between groups. Two interesting facts appear to indicate the presence of ascertainment bias. Differential patient compliance and plaque scores may be hints that the delivery of the test and control interventions differed between the 2 groups being compared. The test group had an acceptable compliance, with almost half of the group following at least 3 of the 5 instructions, but fewer than 10% of the control group reported using the fluoride mouthwash, a clear indication of lack of compliance to the instructions. Plaque scores were also higher among the control group, showing that toothbrushing efficacy was better for the test group than for the control group. These suggestive findings may reflect a more laborious delivery of the test intervention by the care providers or more effort from the participants to comply with the instructions if they knew they were allocated to the intervention being tested. Since blinding of the care providers or participants was not reported and may not have been feasible, 146
we should consider these caveats when interpreting the results of the reviewed study. An additional limitation of the study was that the participants not completing the study were excluded from all analysis, hampering the quasi-random allocation process. Sensitivity analysis, including intent-to-treat analysis, could have been performed to assess the impact of the losses on the results of the trial. Finally, the methods of the reviewed study did not follow the CONSORT recommendations,7 with several aspects not being reported, such as eligibility criteria, blinding to the treatment allocation of outcome assessors, funding, registration number on a trial registry, and availability of a full trial protocol that could be assessed by the reader. In summary, the reviewed study revealed that the use of a modified fluoride toothbrushing technique may significantly reduce the incidence of new carious lesions in orthodontic patients. Although findings from this particular study may not support a change in the recommendation for clinical practice, orthodontists should continue to prevent one of the most common side effects of orthodontic treatment by enforcing simple oral hygiene instructions during orthodontic visits.
REFERENCES 1. Artun J, Brobakken BO. Prevalence of carious white spots after orthodontic treatment with multibonded appliances. Eur J Orthod 1986;8(4):229-34. 2. Gorelick L, Geiger AM, Gwinnett AJ. Incidence of white spot formation after bonding and banding. Am J Orthod Dentofacial Orthop 1982;81(2):93-8. 3. Mizrahi E. Enamel demineralization following orthodontic treatment. Am J Orthod Dentofacial Orthop 1982;82(1):62-7. 4. Ogaard B. Prevalence of white spot lesions in 19-year-olds—a study on untreated and orthodontically treated persons 5 years after treatment. Am J Orthod Dentofacial Orthop 1989;96(5):423-7. 5. Goh H. Interspace/interdental brushes for oral hygiene in orthodontic patients with fixed appliances. Cochrane Database Syst Rev 2007: (3):CD005410. 6. Al Mulla A, Al Kharsa S, Birkhed D. Modified fluoride toothpaste technique reduces caries in orthodontic patients: a longitudinal, randomized clinical trial. Am J Orthod Dentofacial Orthop 2010;285-91. 7. Schulz K, Altman D, Moher D, CONSORT Group. CONSORT 2010 Statement: Updated guidelines for reporting parallel group randomised trials. J Clin Epidemiol 2010;63(8):813-4.
REVIEWER Joana Cunha-Cruz, PhD Research Assistant Professor University of Washington Dental Public Health Sciences, B509 1959 NE Pacific Street Box 357475 Seattle, WA 98195-7475 Phone: (206) 685-6397 Fax: (206) 685-4258 [email protected] September 2011
ARTICLE ANALYSIS & EVALUATION ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION Modified fluoride toothpaste technique reduces caries in orthodontic patients: a longitudinal, randomized clinical trial. Al Mulla AH, Kharsa SA, Birkhed D. Am J Orthod Dentofacial Orthop 2010;138(3):285-91.
REVIEWER Joana Cunha-Cruz, PhD
PURPOSE/QUESTION What is the caries incidence of orthodontic patients using a modified oral hygiene technique compared with orthodontic patients using routine oral hygiene technique?
SOURCE OF FUNDING Information not available
TYPE OF STUDY/DESIGN Randomized controlled trial
Rinsing with Fluoride Toothpaste Slurry may Prevent Dental Caries in Orthodontic Patients SUMMARY Subjects A total of 150 consecutive patients were recruited from a private orthodontic clinic in Riyadh, Saudi Arabia. Participants were quasi-randomly allocated to intervention (test) and control groups based on odd and even birth dates and followed until the end of treatment (2 years). Both baseline and final data analysis included 51 participants in the test group (68% of those originally allocated to intervention; 41 females, mean age 16.2 years) and 49 participants in the control group (65% of those originally allocated to control; 32 females, mean age 16.9 years).
Key Exposure/Study Factor Intervention: Modified toothbrushing technique —brushing teeth after breakfast and before bedtime with toothbrush and fluoride toothpaste for 2 minutes after spreading the toothpaste on the tooth surfaces and rinsing after brushing with toothpaste slurry for 30 seconds. At follow-up, 43% of the participants in the test group were considered to have very good compliance (reported compliance to 3 to 5 out of 5 instructions received) and the remaining were considered to have good compliance (reported compliance to 1 or 2 of the instructions received). Control: Routine oral hygiene instructions —brushing teeth after breakfast and before bedtime with toothbrush and fluoridated toothpaste and rinsing after brushing with fluoridated mouthwash. At follow-up, compliance was poor: 86% used only fluoridated toothpaste, 8% infrequently used fluoride mouthwash, and 6% used neither fluoridated toothpaste nor fluoride mouthwash.
LEVEL OF EVIDENCE Level 2
STRENGTH OF RECOMMENDATION GRADE
Main Outcome Measure Primary outcome —incidence of decayed and filled surfaces (DFS) based on clinical and radiographic examinations using the World Health Organization (WHO) criteria. Secondary outcomes —plaque index using Silness and Loe criteria.
Not applicable
Main Results The DFS incidence was 0.6 (SD = 2.1) for the test group and 3.5 (SD = 4.7) for the control group (P < .001). Prevented fraction was 83%. Plaque index at follow-up was 9.0 (SD = 8.0) for the test group and 11.6 (SD = 10) for the control group (P < .05).
Conclusions J Evid Base Dent Pract 2011;11:145-146 1532-3382/$36.00 Ó 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.jebdp.2011.06.003
The authors concluded that, compared with routine oral hygiene instructions with fluoride toothpaste, the use of a modified fluoride toothbrushing technique significantly reduced the incidence of new carious lesions in orthodontic patients.
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
COMMENTARY AND ANALYSIS Orthodontic patients are at greater risk of developing white spot lesions during orthodontic treatment.1- 4 Several advices and devices have been tested to prevent the development of new caries lesions during orthodontic treatment with questionable efficacy. The clinical trials on the effect of toothbrushing on preventing dental caries in orthodontic patients have mostly focused on types of toothbrushes and on surrogate outcomes such as white spot lesions, gingivitis, and dental plaque.5 The reviewed study proposed a simple modification of the toothbrushing technique commonly used by patients and observed a great benefit for orthodontic patients in preventing dental caries—a clinically relevant end point.6 The main differences of the proposed technique from routine oral hygiene were the spreading of the toothpaste on tooth surfaces before brushing and the rinsing with toothpaste slurry after brushing, instead of fluoride mouthwash. Even though we cannot disentangle which of the modified procedures contributed to the reduction in dental caries, as the authors pointed out, the simplicity of both technique modifications may warrant the use of the modified technique as standard oral hygiene instructions to orthodontic patients. The main limitations of the study were the possible presence of selection and ascertainment biases. The randomized clinical trial was not really random, which may have introduced selection bias. Participants were assigned to the groups by birth date, which is considered a quasirandom process. The treatment allocation then was not concealed, given that by knowing the prospective participant’s birth date one could foresee which treatment the patient would receive. Besides the study not being really random, balance in baseline outcome variables was achieved, for which descriptive statistics were similar between groups. Two interesting facts appear to indicate the presence of ascertainment bias. Differential patient compliance and plaque scores may be hints that the delivery of the test and control interventions differed between the 2 groups being compared. The test group had an acceptable compliance, with almost half of the group following at least 3 of the 5 instructions, but fewer than 10% of the control group reported using the fluoride mouthwash, a clear indication of lack of compliance to the instructions. Plaque scores were also higher among the control group, showing that toothbrushing efficacy was better for the test group than for the control group. These suggestive findings may reflect a more laborious delivery of the test intervention by the care providers or more effort from the participants to comply with the instructions if they knew they were allocated to the intervention being tested. Since blinding of the care providers or participants was not reported and may not have been feasible, 146
we should consider these caveats when interpreting the results of the reviewed study. An additional limitation of the study was that the participants not completing the study were excluded from all analysis, hampering the quasi-random allocation process. Sensitivity analysis, including intent-to-treat analysis, could have been performed to assess the impact of the losses on the results of the trial. Finally, the methods of the reviewed study did not follow the CONSORT recommendations,7 with several aspects not being reported, such as eligibility criteria, blinding to the treatment allocation of outcome assessors, funding, registration number on a trial registry, and availability of a full trial protocol that could be assessed by the reader. In summary, the reviewed study revealed that the use of a modified fluoride toothbrushing technique may significantly reduce the incidence of new carious lesions in orthodontic patients. Although findings from this particular study may not support a change in the recommendation for clinical practice, orthodontists should continue to prevent one of the most common side effects of orthodontic treatment by enforcing simple oral hygiene instructions during orthodontic visits.
REFERENCES 1. Artun J, Brobakken BO. Prevalence of carious white spots after orthodontic treatment with multibonded appliances. Eur J Orthod 1986;8(4):229-34. 2. Gorelick L, Geiger AM, Gwinnett AJ. Incidence of white spot formation after bonding and banding. Am J Orthod Dentofacial Orthop 1982;81(2):93-8. 3. Mizrahi E. Enamel demineralization following orthodontic treatment. Am J Orthod Dentofacial Orthop 1982;82(1):62-7. 4. Ogaard B. Prevalence of white spot lesions in 19-year-olds—a study on untreated and orthodontically treated persons 5 years after treatment. Am J Orthod Dentofacial Orthop 1989;96(5):423-7. 5. Goh H. Interspace/interdental brushes for oral hygiene in orthodontic patients with fixed appliances. Cochrane Database Syst Rev 2007: (3):CD005410. 6. Al Mulla A, Al Kharsa S, Birkhed D. Modified fluoride toothpaste technique reduces caries in orthodontic patients: a longitudinal, randomized clinical trial. Am J Orthod Dentofacial Orthop 2010;285-91. 7. Schulz K, Altman D, Moher D, CONSORT Group. CONSORT 2010 Statement: Updated guidelines for reporting parallel group randomised trials. J Clin Epidemiol 2010;63(8):813-4.
REVIEWER Joana Cunha-Cruz, PhD Research Assistant Professor University of Washington Dental Public Health Sciences, B509 1959 NE Pacific Street Box 357475 Seattle, WA 98195-7475 Phone: (206) 685-6397 Fax: (206) 685-4258 [email protected] September 2011