NIHR Signal Regular use of fluoride mouthrinse is an option to reduce tooth decay in school children
Published on 8 November 2016
A reduction in tooth decay of about 27% can be expected from the supervised regular use of fluoride mouthrinsing by school children.
Tooth decay has a significant impact on health and wellbeing. It is more common in disadvantaged communities and can be prevented by good oral hygiene and diet with reduced sugar intake. Children and young people are encouraged to brush their teeth regularly with fluoride toothpaste and some schools in the UK have supervised programmes to encourage this.
This review included 37 trials where children received supervised mouthrinsing in schools, but did not compare this with supervised toothbrushing.
Current guidance recommends daily use of mouthrinses for children aged eight and over with dental health concerns. These findings suggest there may be a role for extending use as an option to children who don’t already brush their teeth.
Local authority commissioners and practitioners might consider where mouthrinsing sits in current childhood oral health promotion initiatives. Many of these trials were published 30 or more years ago when dental decay was more common.
The place of this school intervention alongside other ways of getting fluoride to the tooth surface will depend on local circumstances and particularly what other ways children might be receiving fluoride.
- Child Health, Oral and dental health, Public Health, Schools and colleges
Why was this study needed?
Tooth decay is the most common chronic condition in children and young people. A third of all children starting school each year have signs of tooth decay and in 1973, this figure was more than nine in ten. Nevertheless tooth extractions are the biggest reason children are admitted to hospital for general anaesthetics in the UK and rates are increasing.
Tooth decay can have many effects including pain and potential school absence, withdrawal from social activities and tooth extraction. Tooth decay tends to be more common in deprived areas and is an important issue in addressing health inequalities.
Decay happens when mouth bacteria break down dietary sugars producing acids which erode the tooth enamel. Fluoride has been shown to prevent this process. Fluoride mouthrinses are commonly used by adults and are sometimes promoted for older children, as part of a package of interventions including regular tooth brushing, flossing and advice on sugar intake. It is important to understand the best advice to offer for schools, parents and local authority commissioners of oral public health.
This Cochrane review is an update of a 2003 review, and is part of a series of reviews looking at different fluoride interventions to prevent tooth decay.
What did this study do?
This updated review found one new trial in addition to 36 identified in 2003. Trials examined supervised mouthrinsing in schools in 15,813 children aged five to 14 years. Most trials compared a fluoride mouthrinse to a placebo, the remaining five compared with no treatment. Trials assessing mouthrinsing against other fluoride applications were excluded.
Trials were of at least one year’s duration, though the fluoride concentration and frequency of mouthrinsing varied, from almost daily to only a few times a year. The main outcome explored was the rate of tooth decay.
Many trials dated from the 1970s and 1980s. The lack of a clear explanation on aspects such as how participants were allocated to the randomised groups means that we can only be moderately confident in the results. Amongst the 37 trials included, thirteen trials were conducted in the USA, with its different health system, and four in the UK.
What did it find?
- Fluoride mouthrinse reduced tooth decay by 27% on average (95% confidence interval [CI] 23% to 30%), as measured by a reduction in the number of decayed, missing, and filled tooth surfaces. This was from pooled analysis of 35 trials in permanent tooth surfaces, which had broadly consistent findings.
- Looking at permanent teeth, fluoride mouthrinse significantly reduced the number of decayed, missing, and filled teeth (rather than surfaces) by 23% (95% CI 0.18 to 0.29). This was from pooled analysis of 13 trials, also with broadly consistent findings.
- Variables such as baseline dental health, fluoride concentration, rinsing frequency, or exposure to fluoride toothpaste or fluoridated water had no apparent influence on the results.
- There was limited data on other outcomes, including adverse effects.
What does current guidance say on this issue?
NICE public health guidance suggests that local authorities and health and wellbeing commissioning partners or head teachers consider supervised tooth brushing scheme for primary schools in high risk areas and if resources are limited, prioritise reception and year one (up to age seven).
Public Health England recommends that fluoride mouthrinses containing at least 1,350ppm fluoride are prescribed for children aged eight years and above if they have tooth decay or their dentist has other cause for concern (for example, if they have a brace). Mouthrinses should be used daily, in addition to twice daily brushing with toothpaste. It is emphasised that mouthrinsing is carried out at a different time from toothbrushing to avoid washing away the protection of the fluoride-containing toothpaste.
What are the implications?
The regular use of fluoride mouthrinses by children could be an important factor in preventing tooth decay for those that cannot brush their teeth. Though these studies did not compare mouthrinses to other fluoride treatments, there may be a case for commissioners and public health practitioners to consider mouthrinsing as one part of good oral hygiene for children.
Schools may play an important role in helping to develop healthy habits as all trials involved supervised mouthrinsing. It is unclear whether children may be motivated to continue by themselves. The lack of safety information and the fact that many trials dated from 30 or more years ago and quality may further limits the interpretation of these findings.
Citation and Funding
Marinho VCC, Chong LY, Worthington HV, et al. Fluoride mouthrinses for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2016;(7):CD002284.
This review was supported by the NIHR, via Cochrane Infrastructure funding to Cochrane Oral Health.
NICE. Oral health: local authorities and partners. PH55. London: National Institute for Health and Care Excellence; 2014.
PHE. Delivering better oral health: an evidence-based toolkit for prevention. 3rd edition. London: Public Health England; 2014.
PHE. Local authorities improving oral health: commissioning better oral health for children and young people. An evidence-informed toolkit for local authorities. London: Public Health England; 2013.
PHE. National Dental Epidemiology Programme for England: oral health survey of five-year-old children 2015. A report on the prevalence and severity of tooth decay. London: Public Health England; 2016.
School-based fluoride rinsing programmes have long been used in North America. This review confirms that fluoride mouthwashes are effective in preventing dental caries when used in such schemes. However, in the UK, school-based tooth brushing schemes are preferred as a means of increasing exposure to fluoride in at-risk children. While there may be merit in comparing mouthrinses with other community based preventive strategies as the authors suggest, rinsing lacks the secondary socialisation aspects of tooth brushing schemes, in encouraging good oral hygiene practices in children who may not otherwise be exposed to regular tooth brushing.
Ivor G Chestnutt, Professor and Hon Consultant in Dental Public Health, Cardiff University
Most trials involved mouthrinses containing sodium fluoride at a concentration from 100 to 3,000 parts per million (ppm), or 0.02% to 0.66%. Public Health England recommends mouthrinses containing 0.05% sodium fluoride – at least 1,350 ppm.
Toothpaste containing between 1,350 and 1,500 ppm of fluoride is thought to be most effective. Children under three years of age are advised to brush twice daily use a smear of toothpaste containing at least 1,000 ppm of fluoride; children aged three to six years, a pea-sized amount. Above this age the recommendation is as for adults, using toothpaste with a concentration of 1,350 to 1,500 ppm.
All children aged three and over, or younger if there is concern, are also advised to have a varnish containing 2.2% sodium fluoride applied to teeth two or more times a year.