这是2010年首次发布的评论的更新。随着时间的推移,使用局部氟化物变得越来越普遍。幼儿局部氟化物消耗过多的氟化物可能会导致恒牙氟中毒。
描述幼儿局部使用氟化物与恒牙氟斑牙风险之间的关系。
我们对Cochrane口腔健康试验登记册进行了电子搜索,中部,MEDLINE,Embase,另外三个数据库,和两个试验记录。我们搜索了相关文章的参考列表。最近的搜索日期是2022年7月28日。
我们纳入了随机对照试验(RCT),准RCT,队列研究,病例对照研究,和比较含氟牙膏的横断面调查,漱口水,凝胶,泡沫,油漆解决方案,和不同氟化物疗法的清漆,安慰剂,或者不干预。在引入局部氟化物后,目标人群是六岁以下的儿童。
我们使用了Cochrane期望的标准方法学程序,并使用GRADE来评估证据的确定性。主要结果指标是恒牙中氟中毒的患病率百分比。两位作者从所有纳入的研究中提取了数据。在报告了调整后和未调整后的风险比或赔率比的情况下,我们在荟萃分析中使用了调整值.
我们纳入了43项研究:三项随机对照试验,四项队列研究,10个病例对照研究,和26项横断面调查。我们判断了所有三个RCT,一项队列研究,一项病例对照研究,和六项横断面研究对偏见风险有一些担忧。我们认为所有其他观察性研究都存在高偏倚风险。我们将这些研究分为五个比较。比较1.儿童开始使用含氟牙膏刷牙的年龄两项队列研究(260名儿童)提供了非常不确定的证据,表明儿童在12个月或之前开始使用含氟牙膏刷牙与12个月后发生氟中毒之间的关联(风险比(RR)0.98,95%置信区间(CI)0.81至1.18;非常低的确定性证据)。同样,来自一项队列研究(3939名儿童)和两项横断面研究(1484名儿童)的证据提供了非常不确定的证据,表明儿童在24个月之前或之后开始使用氟化物牙膏刷牙(RR0.83,95%CI0.61至1.13;非常低的确定性证据)或四年之前或之后(比值比(OR)1.60,95%CI0.77至3.35;非常低的确定性证据),分别。比较2.使用氟化物牙膏刷牙的频率两项病例对照研究(258名儿童)提供了非常不确定的证据,表明儿童每天刷牙少于两次与每天刷牙两次或两次以上与氟中毒发展之间的关联(OR1.63,95%CI0.81至3.28;非常低的确定性证据)。两项横断面调查(1693名儿童)表明,每天刷牙少于一次与每天一次或多次刷牙可能与儿童氟中毒的发展减少有关(OR0.62,95%CI0.53至0.74;低确定性证据)。比较3.用于刷牙的氟化物牙膏的量两项病例对照研究(258名儿童)提供了非常不确定的证据,证明使用不到半刷牙膏的儿童之间的关联。相对于一半或更多的刷子,和氟中毒的发展(OR0.77,95%CI0.41至1.46;非常低的确定性证据)。来自横断面调查的证据也非常不确定(OR0.92,95%CI0.66至1.28;3项研究,2037名儿童;非常低的确定性证据)。比较4.牙膏中的氟化物浓度两项随机对照试验(1968年儿童)的证据表明,六岁以下儿童使用的牙膏中氟化物浓度较低可能会降低患氟中毒的风险:百万分之550(ppm)氟化物与1000ppm(RR0.75,95%CI0.57至0.99;中度确定性证据);440ppm氟化物与1450ppm(RR0.72,95%CI0.58至0.89;中度确定性证据)。开始刷牙的年龄为24个月零12个月,分别。两项病例对照研究(258名儿童)提供了关于1000ppm以下氟化物浓度之间关联的非常不确定的证据。相对于1000ppm或以上的浓度,和氟中毒的发展(OR0.89,95%CI0.52至1.52;非常低的确定性证据)。比较5.使用局部氟化物清漆的年龄来自一项RCT(123名儿童)的证据表明,在四年前使用氟化物清漆之间可能几乎没有差异,与没有应用程序相比,和氟中毒的发展(RR0.77,95%CI0.45至1.31;低确定性证据)。来自两项横断面调查(982名儿童)的低确定性证据表明,在4岁之前局部使用氟化物清漆可能与儿童氟中毒的发展有关(OR2.18,95%CI1.46至3.25)。
大多数证据认为轻度氟中毒是早期使用局部氟化物的潜在不良后果。关于恒牙氟中毒的风险,有低至非常低的确定性和不确定的证据:当儿童开始接受局部氟化物清漆应用时;用氟化物牙膏刷牙;儿童使用的牙膏量;和刷牙的频率。RCT的中度确定性证据表明,从1至2岁到5至6岁,用1000ppm或更多氟化物牙膏刷牙的儿童可能会增加恒牙氟斑牙的机会。提出新的RCT来评估氟斑牙的发展是不道德的。然而,未来以龋齿预防为重点的随机对照试验可以记录儿童在生命早期暴露于局部氟化物源的情况,并将其恒牙中的氟斑牙作为长期结果进行评估.在缺乏这些研究和方法的情况下,这方面的进一步研究将来自观测研究。需要注意研究设计的选择,考虑到前瞻性对照研究比回顾性和非对照研究更不容易出现偏倚.
This is an update of a review first published in 2010. Use of topical fluoride has become more common over time. Excessive fluoride consumption from topical fluorides in young children could potentially lead to dental fluorosis in permanent teeth.
To describe the relationship between the use of topical fluorides in young children and the risk of developing dental fluorosis in permanent teeth.
We carried out electronic searches of the Cochrane Oral Health Trials Register, CENTRAL, MEDLINE, Embase, three other databases, and two trials registers. We searched the reference lists of relevant articles. The latest search date was 28 July 2022.
We included randomized controlled trials (RCTs), quasi-RCTs, cohort studies, case-control studies, and cross-sectional surveys comparing fluoride toothpaste, mouth rinses, gels, foams, paint-on solutions, and varnishes to a different fluoride therapy, placebo, or no intervention. Upon the introduction of topical fluorides, the target population was children under six years of age.
We used standard methodological procedures expected by Cochrane and used GRADE to assess the certainty of the evidence. The primary outcome measure was the percentage prevalence of fluorosis in the permanent teeth. Two authors extracted data from all included studies. In cases where both adjusted and unadjusted risk ratios or odds ratios were reported, we used the adjusted value in the meta-analysis.
We included 43 studies: three RCTs, four cohort studies, 10 case-control studies, and 26 cross-sectional surveys. We judged all three RCTs, one cohort study, one case-control study, and six cross-sectional studies to have some concerns for risk of bias. We judged all other observational studies to be at high risk of bias. We grouped the studies into five comparisons. Comparison 1. Age at which children started toothbrushing with fluoride toothpaste Two cohort studies (260 children) provided very uncertain evidence regarding the association between children starting to use fluoride toothpaste for brushing at or before 12 months versus after 12 months and the development of fluorosis (risk ratio (RR) 0.98, 95% confidence interval (CI) 0.81 to 1.18; very low-certainty evidence). Similarly, evidence from one cohort study (3939 children) and two cross-sectional studies (1484 children) provided very uncertain evidence regarding the association between children starting to use fluoride toothpaste for brushing before or after the age of 24 months (RR 0.83, 95% CI 0.61 to 1.13; very low-certainty evidence) or before or after four years (odds ratio (OR) 1.60, 95% CI 0.77 to 3.35; very low-certainty evidence), respectively. Comparison 2. Frequency of toothbrushing with fluoride toothpaste Two case-control studies (258 children) provided very uncertain evidence regarding the association between children brushing less than twice per day versus twice or more per day and the development of fluorosis (OR 1.63, 95% CI 0.81 to 3.28; very low-certainty evidence). Two cross-sectional surveys (1693 children) demonstrated that brushing less than once per day versus once or more per day may be associated with a decrease in the development of fluorosis in children (OR 0.62, 95% CI 0.53 to 0.74; low-certainty evidence). Comparison 3. Amount of fluoride toothpaste used for toothbrushing Two case-control studies (258 children) provided very uncertain evidence regarding the association between children using less than half a brush of toothpaste, versus half or more of the brush, and the development of fluorosis (OR 0.77, 95% CI 0.41 to 1.46; very low-certainty evidence). The evidence from cross-sectional surveys was also very uncertain (OR 0.92, 95% CI 0.66 to 1.28; 3 studies, 2037 children; very low-certainty evidence). Comparison 4. Fluoride concentration in toothpaste There was evidence from two RCTs (1968 children) that lower fluoride concentration in the toothpaste used by children under six years of age likely reduces the risk of developing fluorosis: 550 parts per million (ppm) fluoride versus 1000 ppm (RR 0.75, 95% CI 0.57 to 0.99; moderate-certainty evidence); 440 ppm fluoride versus 1450 ppm (RR 0.72, 95% CI 0.58 to 0.89; moderate-certainty evidence). The age at which the toothbrushing commenced was 24 months and 12 months, respectively. Two case-control studies (258 children) provided very uncertain evidence regarding the association between fluoride concentrations under 1000 ppm, versus concentrations of 1000 ppm or above, and the development of fluorosis (OR 0.89, 95% CI 0.52 to 1.52; very low-certainty evidence). Comparison 5. Age at which topical fluoride varnish was applied There was evidence from one RCT (123 children) that there may be little to no difference between a fluoride varnish application before four years, versus no application, and the development of fluorosis (RR 0.77, 95% CI 0.45 to 1.31; low-certainty evidence). There was low-certainty evidence from two cross-sectional surveys (982 children) that the application of topical fluoride varnish before four years of age may be associated with the development of fluorosis in children (OR 2.18, 95% CI 1.46 to 3.25).
Most evidence identified mild fluorosis as a potential adverse outcome of using topical fluoride at an early age. There is low- to very low-certainty and inconclusive evidence on the risk of having fluorosis in permanent teeth for: when a child starts receiving topical fluoride varnish application; toothbrushing with fluoride toothpaste; the amount of toothpaste used by the child; and the frequency of toothbrushing. Moderate-certainty evidence from RCTs showed that children who brushed with 1000 ppm or more fluoride toothpaste from one to two years of age until five to six years of age probably had an increased chance of developing dental fluorosis in permanent teeth. It is unethical to propose new RCTs to assess the development of dental fluorosis. However, future RCTs focusing on dental caries prevention could record children\'s exposure to topical fluoride sources in early life and evaluate the dental fluorosis in their permanent teeth as a long-term outcome. In the absence of these studies and methods, further research in this area will come from observational studies. Attention needs to be given to the choice of study design, bearing in mind that prospective controlled studies will be less susceptible to bias than retrospective and uncontrolled studies.