Two Cochrane reviews (Marinho et al 2003, Walsh et al 2010) have suggested additional benefit from fluoridated toothpaste in children and adolescents when toothbrushing is supervised and a number of guidance documents including the 2014 Scottish Intercollegiate Guidelines Network (SIGN) guideline recommend supervised toothbrushing.
The aim of this new review was to assess the effects of supervised toothbrushing per se on caries incidence in children and adolescents.
Searches were conducted in the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Web of Science, Embase, LILACS, BBO, Open Grey, EThOS, Banco de Teses CAPES, Current Controlled Trials and ClinicalTrials.gov databases. Meeting abstracts of the International Association for Dental Research (2001–2016) and the European Organisation for Caries Research (1998–2016) were also searched. Randomised or quasi-randomised controlled trials (RCTs) with at least 1 year follow up were considered. Two reviewers independently abstracted data and assessed risk of bias. Because of study heterogeneity no meta-analysis was conducted.
- 4 studies were included all being conducted in schools.
- Children’s age, caries risk and toothpaste fluoride concentration all differed.
- All studies had a high risk of bias.
- two studies statistically significant differences favouring supervised toothbrushing, but information about the magnitude and/or the precision of the effect estimate was lacking and in one trial clustering effect was not taken into consideration.
The authors concluded: –
no conclusive evidence that supervised toothbrushing increases the anti-caries benefit provided by F toothpastes. For supervision during toothbrushing to be widely recommended and adopted, high-quality trials with proper control groups should confirm whether caries could be reduced further by supervising children when they are brushing their teeth with F toothpaste.
The introduction to this review highlights the potential benefits of supervised brushing as improving brushing technique, longer brushing times, greater frequency and reduced caries. In the SIGN guideline 138 section on supervised brushing it problems in relation to a standard definition to ‘supervision’ which creates difficulties for reviewer and needs to be better reported in the literature.
As the 2003 Cochrane review also included RCTs of one year duration it is interesting to note that their sensitivity analysis highlighted a 10% lower preventive fraction (95%CI; -17 to -4%; P = 0.001) with unsupervised toothbrushing. Although the later Cochrane review by Walsh et al only found a non-statistically significant benefit in favour of supervised toothbrushing. Both the Cochrane review included more studies in their analyses than the current review. The difference between the review could be related to the way in which ‘supervision’ is interpretation and while further high quality studies would be helpful as noted above greater clarity regarding the type an quality of the supervision needs to be recorded.
Santos APPD, de Oliveira BH, Nadanovsky P. A systematic review of the effects of supervised toothbrushing on caries incidence in children and adolescents. Int J Paediatr Dent. 2017 Sep 21. doi:10.1111/ipd.12334. [Epub ahead of print] Review. PubMed PMID: 28940755.
Marinho VC, Higgins JP, Sheiham A, Logan S. Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2003;(1):CD002278. Review. PubMed PMID: 12535435.
Walsh T, Worthington HV, Glenny AM, Appelbe P, Marinho VCC, Shi X. Fluoride toothpastes of different concentrations for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD007868. DOI: 10.1002/14651858.CD007868.pub2.
Dental Elf – 27th Jun 2016
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