This is the current release of the guideline.

Dental caries

Infants and children aged 6 months to 16 years who live in communities without fluoridated water or with water of low fluoride content

Occurrence of dental fluorosis and dental caries in infants and children aged 6 months to 16 years

A panel of experts convened by the American Dental Association (ADA) Council on Scientific Affairs (CSA), in collaboration with staff of the ADA Center for Evidence-based Dentistry, conducted a MEDLINE search to identify publications that addressed the research questions: systematic reviews as well as clinical studies published since the systematic reviews were conducted (June 1, 2006).

Search Strategies

Systematic Reviews

ADA staff conducted a literature search for systematic reviews published in English as of May 14, 2008, by using PubMed and the following search terms: "fluoride supplements," "vitamin" OR "fluoride supplements," "tablet" OR "fluoride supplements," "chewable" OR "fluoride supplements," "drop" OR "fluoride supplements," "lozenges" AND "dental caries" OR "demineralization" OR "remineralization" OR "cariostatic" OR "anticaries" (tw) OR "anticaries" (tw) OR "fluorosis," "dental" OR "fluorosis," "enamel" OR "mottled" AND "systematic" (sb). (Note: "tw" means "text word"; "sb" means "subset.")

Two investigators on the ADA staff conducted the search on May 14, 2008. The initial search yielded 136 articles. The same two investigators conducted a title review for relevance to the clinical questions. They identified 46 articles. They also screened abstracts of these 46 articles, which yielded 23 articles for consideration. They conducted a full-text review of the 23 articles. Their reviews included systematic reviews that either included or did not include meta-analyses, as evidenced by use of the terms in the publication, or that had key features of a systematic review such as a comprehensive literature search and two independent reviewers. Inclusion criteria were as follows:

• Human participants
• Publication in the English language
• Patients who had been exposed to fluoride supplements
• Evidence provided to answer the clinical questions
• Reported outcomes of either caries or enamel fluorosis
• Examination of patients to determine presence of caries or enamel fluorosis
• For caries-prevention studies, a study design that included both control and experimental groups.

Ultimately, the two investigators included two systematic reviews for consideration by the expert panel. The investigators also included for the panel's review a systematic review by Ismail and colleagues that had been accepted for publication but not yet published.

Appendix 1 in the supplemental data to the online version of this article (see the "Availability of Companion Documents" field) provides the complete list of the excluded publications.

One of the authors updated the literature search for systematic reviews to include only articles published between May 14, 2008, and Dec. 11, 2009. She used the same search terms as described above. She and another independent reviewer identified and screened 23 citations (full text and abstract). They did not identify any new systematic reviews. Then she conducted the search again to include only articles published between Dec. 11, 2009, and June 16, 2010, using the same search terms as described above. She and the other independent reviewer identified and screened the abstracts of three citations. They did not identify any new systematic reviews.

Clinical Studies

Two researchers searched for recently published clinical studies related to the clinical questions. They conducted their search on the basis of the search date used in the most recent systematic review, which Ismail and Hasson published in 2008. In that systematic review, the authors conducted a literature search on June 1, 2006. Thus, the researchers limited their search to articles published from June 1, 2006, through May 14, 2008. The two researchers conducted a literature search for clinical studies published in English by using PubMed and the following search terms: "fluoride supplements," "vitamin" OR "fluoride supplements," "tablet" OR "fluoride supplements," "chewable" OR "fluoride supplements," "drop" OR "fluoride supplements," "lozenges" AND "dental caries" OR "demineralization" OR "remineralization" OR "cariostatic" OR "anti-caries" (tw) OR "anticaries" (tw) OR "fluorosis," "dental" OR "fluorosis," "enamel" OR "mottled." The initial search yielded 987 articles. The researchers screened titles and reduced the number to 51 clinical studies that related to the clinical questions. Screening of the abstracts yielded 25 articles for full-text review, two of which the researchers included for consideration by the expert panel but which, ultimately, the panel excluded because they were not relevant to the clinical question.

The inclusion criteria were as described earlier for the systematic review search. Appendix 2 in the supplemental data to the online version of this article (see the "Availability of Companion Documents" field) provides the complete list of excluded publications.

One of the authors updated the literature search for clinical studies to include only articles published between May 14, 2008, and Dec. 11, 2009. She used the same search terms as described above. She and another independent reviewer identified and screened 754 citations (titles and abstracts). They selected three articles for full-text review. Of these, the panel considered only one study that met the inclusion criteria. The panel became aware of one additional report that had been accepted for publication, but not yet published, by The Journal of the American Dental Association. The panel included these two studies.

Then the same author updated the literature search for clinical studies published between Dec. 11, 2009, and June 16, 2010. She used the same search terms as described above. She and the other independent reviewer identified and screened 222 citations (titles and abstracts). They identified no additional studies.

The panel included in its evaluations three systematic reviews and two clinical studies related to the clinical questions.

The panel performed a qualitative assessment of the strengths and limitations of each included systematic review or clinical study to determine the quality of the evidence. The panel developed evidence statements that were based on the literature, then graded the evidence according to a system modified by Shekelle and colleagues (see the "Rating Scheme for the Strength of the Evidence" field).

The panelists also analyzed the individual studies in the systematic reviews in which investigators addressed caries prevention, looking for evidence related to specific schedules according to age group and level of fluoride in the community water supply. The included studies were not limited to the United States and were conducted in areas with varying levels of fluoride in the community water supply. Appendices 1 and 2 in the supplemental data to the online version of this article (see the "Availability of Companion Documents" field) list the excluded publications. The panelists considered the body of evidence and drafted the evidence statements listed in Table 2 in the original guideline document. Although investigators in many of the included studies addressed the clinical questions, many of the studies had methodological limitations. Also, some are from an earlier era of fluoride supplement research, during which caries incidence was higher and there were fewer sources of fluoride exposure than there are now.

Expert Panel

In July 2008, the American Dental Association (ADA) Council on Scientific Affairs (CSA) convened an expert panel to develop recommendations addressing the following questions:

• When and for whom should fluoride supplements be prescribed?
• What should be the recommended dosage schedule for dietary fluoride supplements?

The panel of 10 experts evaluated systematically the collective scientific evidence related to the clinical questions listed above and developed evidence-based clinical recommendations for the prescription of dietary fluoride supplements.

The Council selected panelists on the basis of their expertise in the relevant subject matter. The expert panel convened at a workshop held July 16-18, 2008, at the ADA Headquarters in Chicago. The panelists continued their work by means of conference calls to finalize the recommendations and develop this report.

Grading the Evidence and Classifying the Strength of the Clinical Recommendations

The panel performed a qualitative assessment of the strengths and limitations of each included systematic review or clinical study to determine the quality of the evidence. The panel developed evidence statements that were based on the literature, then graded the evidence according to a system modified by Shekelle and colleagues (see the "Rating Scheme for the Strength of the Evidence" field). The panel then developed the clinical recommendations according to the evidence statements.

Using the same modified system (see the "Rating Scheme for the Strength of the Recommendations" field), the panel classified the clinical recommendations on the strength of the evidence reviewed. Although the classification of the recommendation may not directly reflect the importance of the recommendation, it does reflect the quality of scientific evidence that supports the recommendation.

A formal cost analysis was not performed and published cost analyses were not reviewed.

Appendix 3 in the supplemental data online (see the "Availability of Companion Documents" field) lists the numerous scientific experts and organizations that reviewed this document. The panelists evaluated all comments received and made appropriate revisions. The Council on Scientific Affairs approved the final clinical recommendations.

The levels of evidence (Ia-IV) and the classification of recommendations (A-D) are defined at the end of the "Major Recommendations" field.

Definitions:

Levels of Evidence

Classification of Recommendations

None provided

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

The clinical recommendations are intended as a resource for use by dentists and other health care providers. The recommendations must be balanced with the practitioner's professional judgment and the individual patient's needs and preferences. The scope of review for this panel did not include recommendations for school-based or other dental public health programs such as the federal Head Start program.

An implementation strategy was not provided.

Not applicable: The guideline was not adapted from another source.

American Dental Association

American Dental Association Council on Scientific Affairs Expert Panel

Panel Members: R. Gary Rozier, DDS, MPH; Steven Adair, DDS, MS; Frank Graham, DMD; Timothy Iafolla, DMD, MPH; Albert Kingman, PhD; William Kohn, DDS; David Krol, MD, MPH; Steven Levy, DDS, MPH; Howard Pollick, BDS, MPH; Gary Whitford, PhD, DMD; Sheila Strock, DMD, MPH; Julie Frantsve-Hawley, RDH, PhD; Krishna Aravamudhan, BDS, MS; Daniel M. Meyer, DDS

The panel comprised 10 members who represented a broad range of expertise in dentistry, children's oral health or both. All panelists completed a standard conflict-of-interest questionnaire.

Disclosures

Dr. Adair is the chief dental officer, FORBA Dental Management, Nashville. None of the other authors reported any disclosures.

This is the current release of the guideline.

Electronic copies: Available in Portable Document Format (PDF) from the American Dental Association Web site .

Print copies: Available from the American Dental Association, 211 E. Chicago Avenue, Chicago, IL 60611

The following are available:

• Evidence-based clinical recommendations on the prescription of dietary fluoride supplements for caries prevention supplemental data. A report of the American Dental Association Council on Scientific Affairs; 2010. 15 p. Electronic copies: Available in Portable Document Format (PDF) from the American Dental Association (ADA) Web site .
• Dietary fluoride supplements: evidence-based clinical recommendations. Chair-side guide. American Dental Association Council on Scientific Affairs; 2010. 2 p. Electronic copies: Available in PDF from the ADA Web site .

The following are available:

• Fluoride supplements. Patient version. Available from the American Dental Association (ADA)Web site .
• Fluorosis. Patient version. Available from the ADA Web site .

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

This NGC summary was completed by ECRI Institute on January 31, 2012. The information was verified by the guideline developer on February 8, 2012.

This NGC summary (abstracted American Dental Association Guideline) is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

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