Cochrane · intervention · CD007693
Topical fluoride as a cause of dental fluorosis in children
Wong, MC, Zhang, R, Luo, BW, et al. · Cochrane Database of Systematic Reviews · 2024 · Cochrane Library
Full textEvery question was extracted from the full review (methods and results), not only its Summary of Findings table.
Questions
20
current version
GRADE rated
18
No studies
0
Included studies
43
as reported
No studies 0 · 0%Ungraded 2 · 10%Very low 13 · 65%Low 3 · 15%Moderate 2 · 10%High 0 · 0%
Ungraded means an effect was reported without a GRADE rating; it is not a gap. No studies means the review found nothing to answer the question. The six categories are a display order, not a score.
Review question
| Element | Planned (methods) | Found (results) |
|---|---|---|
| Population | Children exposed to topical fluoride when under six years old, with at least one permanent tooth that could be checked clinically up to 18 years (6 to 18 years of age) | Children aged 6 to 18 years at the time of fluorosis assessment; 32,181 participants |
| Intervention | Topical fluoride therapy (TFT) in the form of toothpaste, mouth rinses, gels, foams, paint-on solutions and varnishes, using any fluoride agent, at any concentration (ppm F), amount or duration of application, provided the frequency of application was at least once a year | Fluoride toothpaste (n=39); Fluoride varnish (n=3); Fluoride mouth rinse (n=1) |
| Comparison | Alternative fluoride treatment; Placebo; No intervention | Alternative fluoride treatment; Placebo; No intervention |
| Outcomes | Percentage prevalence of fluorosis in the permanent teeth | Percentage prevalence of fluorosis (n=43) |
| Study designs | Randomized controlled trials (RCTs), quasi-RCTs, cohort studies, case-control studies, and cross-sectional surveys | RCT (n=3); Cohort study (n=4); Case-control study (n=10); Cross-sectional survey (n=26) |
| Timing | When most of the permanent teeth of interest had erupted | Fluorosis assessed at 6 to 18 years |
Search date: 2022-07. Databases: Cochrane Oral Health Trials Register; Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE Ovid; Embase Ovid; BIOSIS; LILACS BIREME Virtual Health Library; ProQuest Dissertations and Theses Global; US National Institutes of Health Trials Registry (ClinicalTrials.gov); World Health…
Questions and results
Current version onlyStarted toothbrushing with fluoride toothpaste before 24 months (earlier start) vs Started after 24 months (later start)
Population: Children exposed to topical fluoride when under 6 years old; fluorosis assessed in permanent teeth at 6 to 18 years
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Fluorosis (percentage prevalence in permanent teeth) Fluorosis assessed when most permanent teeth of interest had erupted (6 to 18 years) | OR 2.25 [1.19, 4.23] | 6 studies · 1223 participants | Very low Downgraded: risk of bias, inconsistency |
Started toothbrushing with fluoride toothpaste before 12 months (earlier start) vs Started after 12 months (later start)
Population: Children exposed to topical fluoride when under 6 years old; fluorosis assessed in permanent teeth at 6 to 18 years
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Fluorosis (percentage prevalence in permanent teeth) Fluorosis assessed when most permanent teeth of interest had erupted (6 to 18 years) | OR 1.22 [0.98, 1.52] | 7 studies · 4329 participants | Very low Downgraded: risk of bias, inconsistency |
Started toothbrushing with fluoride toothpaste at or before 24 months (earlier start) vs Started after 24 months (later start)
Population: Children exposed to topical fluoride when under 6 years old; fluorosis assessed in permanent teeth at 6 to 18 years
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Fluorosis (percentage prevalence in permanent teeth) Fluorosis assessed when most permanent teeth of interest had erupted (6 to 18 years) | OR 1.12 [0.89, 1.42] | 5 studies · 3592 participants | Very low Downgraded: risk of bias, imprecision |
Brushed less than twice per day vs Brushed twice or more per day
Population: Children exposed to topical fluoride when under 6 years old; fluorosis assessed in permanent teeth at 6 to 18 years
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Fluorosis (percentage prevalence in permanent teeth) Fluorosis assessed when most permanent teeth of interest had erupted (6 to 18 years) | OR 0.88 [0.71, 1.08] | 3 studies · 2037 participants | Very low Downgraded: risk of bias, imprecision |
Used a pea-sized amount of fluoride toothpaste or less vs Used more than a pea-sized amount
Population: Children exposed to topical fluoride when under 6 years old; fluorosis assessed in permanent teeth at 6 to 18 years
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Fluorosis (percentage prevalence in permanent teeth) Fluorosis assessed when most permanent teeth of interest had erupted (6 to 18 years) | OR 0.92 [0.66, 1.28] 38% vs 36% | 3 studies · 2037 participants | Very low Downgraded: risk of bias, imprecision, inconsistency |
Fluoride toothpaste 550 ppm (lower concentration) vs Fluoride toothpaste 1000 ppm (higher concentration)
Population: Children exposed to topical fluoride when under 6 years old; fluorosis assessed in permanent teeth at 6 to 18 years
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Fluorosis (percentage prevalence in permanent teeth) Fluorosis assessed when most permanent teeth of interest had erupted (6 to 18 years) | RR 0.75 [0.57, 0.99] 18% vs 14% | 1 study · 959 participants | Moderate Downgraded: risk of bias |
Fluoride toothpaste 440 ppm (lower concentration) vs Fluoride toothpaste 1450 ppm (higher concentration)
Population: Children exposed to topical fluoride when under 6 years old; fluorosis assessed in permanent teeth at 6 to 18 years
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Fluorosis (percentage prevalence in permanent teeth) Fluorosis assessed when most permanent teeth of interest had erupted (6 to 18 years) | RR 0.72 [0.58, 0.89] 26% vs 19% | 1 study · 1009 participants | Moderate Downgraded: risk of bias |
Fluoride toothpaste less than 1000 ppm (lower concentration) vs Fluoride toothpaste 1000 ppm or more (higher concentration)
Population: Children exposed to topical fluoride when under 6 years old; fluorosis assessed in permanent teeth at 6 to 18 years
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Fluorosis (percentage prevalence in permanent teeth) Fluorosis assessed when most permanent teeth of interest had erupted (6 to 18 years) | OR 0.79 [0.62, 1.02] | 3 studies · 2037 participants | Very low Downgraded: risk of bias, imprecision |
Started toothbrushing with fluoride toothpaste at or before 12 months (earlier start) vs Started after 12 months (later start)
Population: Children exposed to topical fluoride when under 6 years old; fluorosis assessed in permanent teeth at 6 to 18 years
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Fluorosis (percentage prevalence in permanent teeth) Fluorosis assessed when most permanent teeth of interest had erupted (6 to 18 years) | RR 0.98 [0.81, 1.18] 64% vs 63% | 2 studies · 260 participants | Very low Downgraded: risk of bias, imprecision |
Started toothbrushing with fluoride toothpaste at or before 24 months (earlier start) vs Started after 24 months (later start)
Population: Children exposed to topical fluoride when under 6 years old; fluorosis assessed in permanent teeth at 6 to 18 years
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Fluorosis (percentage prevalence in permanent teeth) Fluorosis assessed when most permanent teeth of interest had erupted (6 to 18 years) | RR 0.83 [0.61, 1.13] 12% vs 10% | 1 study · 3939 participants | Very low Downgraded: risk of bias, imprecision |
Started toothbrushing with fluoride toothpaste at or before 12 months (earlier start) vs Started after 12 months (later start)
Population: Children exposed to topical fluoride when under 6 years old; fluorosis assessed in permanent teeth at 6 to 18 years
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Fluorosis (percentage prevalence in permanent teeth) Fluorosis assessed when most permanent teeth of interest had erupted (6 to 18 years) | OR 0.83 [0.41, 1.67] | 1 study · 134 participants | Very low Downgraded: risk of bias, imprecision |
Started toothbrushing with fluoride toothpaste before 4 years (earlier start) vs Started after 4 years (later start)
Population: Children exposed to topical fluoride when under 6 years old; fluorosis assessed in permanent teeth at 6 to 18 years
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Fluorosis (percentage prevalence in permanent teeth) Fluorosis assessed when most permanent teeth of interest had erupted (6 to 18 years) | OR 1.60 [0.77, 3.35] 53% vs 64% | 2 studies · 1484 participants | Very low Downgraded: risk of bias, imprecision, inconsistency |
Brushed less than twice per day vs Brushed twice or more per day
Population: Children exposed to topical fluoride when under 6 years old; fluorosis assessed in permanent teeth at 6 to 18 years
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Fluorosis (percentage prevalence in permanent teeth) Fluorosis assessed when most permanent teeth of interest had erupted (6 to 18 years) | OR 1.63 [0.81, 3.28] 42% vs 54% | 2 studies · 258 participants | Very low Downgraded: risk of bias, imprecision |
Brushed less than once per day vs Brushed once or more per day
Population: Children exposed to topical fluoride when under 6 years old; fluorosis assessed in permanent teeth at 6 to 18 years
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Fluorosis (percentage prevalence in permanent teeth) Fluorosis assessed when most permanent teeth of interest had erupted (6 to 18 years) | OR 0.62 [0.53, 0.74] 54% vs 42% | 2 studies · 1693 participants | Low Downgraded: risk of bias |
Used less than half of the brush of fluoride toothpaste vs Used half or more of the brush
Population: Children exposed to topical fluoride when under 6 years old; fluorosis assessed in permanent teeth at 6 to 18 years
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Fluorosis (percentage prevalence in permanent teeth) Fluorosis assessed when most permanent teeth of interest had erupted (6 to 18 years) | OR 0.77 [0.41, 1.46] 42% vs 36% | 2 studies · 258 participants | Very low Downgraded: risk of bias, imprecision |
Fluoride toothpaste less than 1000 ppm (lower concentration) vs Fluoride toothpaste 1000 ppm or more (higher concentration)
Population: Children exposed to topical fluoride when under 6 years old; fluorosis assessed in permanent teeth at 6 to 18 years
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Fluorosis (percentage prevalence in permanent teeth) Fluorosis assessed when most permanent teeth of interest had erupted (6 to 18 years) | OR 0.89 [0.52, 1.52] 42% vs 39% | 2 studies · 258 participants | Very low Downgraded: risk of bias, imprecision |
Fluoride varnish applied before 4 years of age (biannual) vs Placebo varnish
Population: Children exposed to topical fluoride when under 6 years old; fluorosis assessed in permanent teeth at 6 to 18 years
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Fluorosis (percentage prevalence in permanent teeth) Fluorosis assessed when most permanent teeth of interest had erupted (6 to 18 years) | RR 0.77 [0.45, 1.31] 35% vs 27% | 1 study · 123 participants | Low Downgraded: risk of bias, imprecision |
Fluoride varnish applied before 4 years of age vs No fluoride varnish application
Population: Children exposed to topical fluoride when under 6 years old; fluorosis assessed in permanent teeth at 6 to 18 years
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Fluorosis (percentage prevalence in permanent teeth) Fluorosis assessed when most permanent teeth of interest had erupted (6 to 18 years) | OR 2.18 [1.46, 3.25] 45% vs 64% | 2 studies · 982 participants | Low Downgraded: risk of bias |
Ate or licked fluoride toothpaste vs Did not eat or lick fluoride toothpaste
Population: Children exposed to topical fluoride when under 6 years old; fluorosis assessed in permanent teeth at 6 to 18 years
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Fluorosis (percentage prevalence in permanent teeth) Fluorosis assessed when most permanent teeth of interest had erupted (6 to 18 years) | Nine studies investigated whether children ate or licked toothpaste; measurement subjective so not meta-analyzed (Table 1). Findings mixed: some studies found no significant difference; others (e.g. Celeste 2016 OR up… | 9 studies | Ungraded |
Used fluoride mouth rinse vs No fluoride mouth rinse
Population: Children exposed to topical fluoride when under 6 years old; fluorosis assessed in permanent teeth at 6 to 18 years
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Fluorosis (percentage prevalence in permanent teeth) Fluorosis assessed when most permanent teeth of interest had erupted (6 to 18 years) | OR 1.44 [0.62, 3.38] | 1 study | Ungraded |
Started toothbrushing with fluoride toothpaste after 24 months (later start) vs Started at or before 24 months (earlier start)
Population: Children who used topical fluoride under 6 years old; fluorosis assessed in permanent teeth at 6 to 17 years
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Fluorosis (percentage prevalence in permanent teeth) Fluorosis assessed when most permanent teeth of interest had erupted (6 to 17 years) | OR 0.29 [0.15, 0.53] | 2 studies | Ungraded |
Started toothbrushing with fluoride toothpaste after 12 to 14 months (later start) vs Started at or before 12 to 14 months (earlier start)
Population: Children who used topical fluoride under 6 years old; fluorosis assessed in permanent teeth at 6 to 17 years
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Fluorosis (percentage prevalence in permanent teeth) Fluorosis assessed when most permanent teeth of interest had erupted (6 to 17 years) | OR 0.70 [0.57, 0.88] | 4 studies | Ungraded |
Started toothbrushing with fluoride toothpaste at or before 24 months (earlier start) vs Started after 24 months (later start)
Population: Children who used topical fluoride under 6 years old; fluorosis assessed in permanent teeth at 6 to 17 years
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Fluorosis (percentage prevalence in permanent teeth) Fluorosis assessed when most permanent teeth of interest had erupted (6 to 17 years) | OR 0.92 [0.71, 1.18] | 5 studies | Ungraded |
Brushed less than twice per day vs Brushed twice or more per day
Population: Children who used topical fluoride under 6 years old; fluorosis assessed in permanent teeth at 6 to 17 years
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Fluorosis (percentage prevalence in permanent teeth) Fluorosis assessed when most permanent teeth of interest had erupted (6 to 17 years) | OR 0.88 [0.71, 1.08] | 3 studies | Ungraded |
Used a small or pea-sized amount of fluoride toothpaste (or less) vs Used a medium-to-large or more than pea-sized amount
Population: Children who used topical fluoride under 6 years old; fluorosis assessed in permanent teeth at 6 to 17 years
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Fluorosis (percentage prevalence in permanent teeth) Fluorosis assessed when most permanent teeth of interest had erupted (6 to 17 years) | OR 0.92 [0.67, 1.28] | 3 studies | Ungraded |
Fluoride toothpaste 550 ppm (lower concentration) vs Fluoride toothpaste 1000 ppm (higher concentration)
Population: Children who used topical fluoride under 6 years old; fluorosis assessed in permanent teeth at 6 to 17 years
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Fluorosis (percentage prevalence in permanent teeth) Fluorosis assessed when most permanent teeth of interest had erupted (6 to 17 years) | RR 0.75 [0.57, 0.99] | 1 study | Ungraded |
Fluoride toothpaste 440 ppm (lower concentration) vs Fluoride toothpaste 1450 ppm (higher concentration)
Population: Children who used topical fluoride under 6 years old; fluorosis assessed in permanent teeth at 6 to 17 years
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Fluorosis (percentage prevalence in permanent teeth) Fluorosis assessed when most permanent teeth of interest had erupted (6 to 17 years) | RR 0.59 [0.44, 0.79] | 1 study | Ungraded |
Fluoride toothpaste less than 1000 ppm (lower concentration) vs Fluoride toothpaste 1000 ppm or more (higher concentration)
Population: Children who used topical fluoride under 6 years old; fluorosis assessed in permanent teeth at 6 to 17 years
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Fluorosis (percentage prevalence in permanent teeth) Fluorosis assessed when most permanent teeth of interest had erupted (6 to 17 years) | OR 0.79 [0.61, 1.02] | 3 studies | Ungraded |
Topical fluoride therapy (toothpaste, mouthrinse, gel, foam, paint-on solution, or varnish; any agent, concentration, amount or duration; frequency at least once a year) vs Alternative topical fluoride therapy, placebo, or no intervention
Population: Children under the age of 6 at the time topical fluorides are used
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Percentage prevalence of fluorosis in permanent teeth When most permanent teeth of interest are erupted | no estimate extracted | NR | No studies |