Objectives: Fluoride varnish (FV) is efficacious in caries prevention although its effects among different tooth surfaces are poorly understood. This study sought to determine the extent to which caries-preventive effects of a community intervention that included FV application among preschool-aged children varied according to primary tooth anatomy and baseline tooth pathology. Methods: Secondary analysis was undertaken of data from a community-randomized controlled trial among 543 3- to 5-year-old Aboriginal children in 30 Northern Territory Australian communities. Children in intervention communities received community health promotion and FV application once every 6 months. Net caries (d3mfs) risk and 95% confidence limits (CL) were estimated for the control and intervention arms, and stratified according to tooth anatomy/location and baseline pathology (sound, enamel opacity, hypoplastic defect or precavitated carious lesion). The intervention’s efficacy was quantified using generalized estimating equation modeling accounting for study design and clustering. The assumption of efficacy homogeneity was tested using a Wald χ2 test with a p < 0.2 criterion and post hoc pairwise comparisons. Results: The intervention resulted in a 25% reduction (relative risk, RR = 0.75; 95% CL = 0.71, 0.80) in the 2-year surface-level caries risk. There was substantial heterogeneity in FV efficacy by baseline surface pathology: RRs were 0.73 for sound, 0.77 for opaque, 0.90 for precavitated, and 0.92 for hypoplastic surfaces. Among sound surfaces, maxillary anterior facials received significantly more benefit (RR = 0.62) compared to pits and fissures (RR = 0.78). Conclusion: The intervention had greatest efficacy on surfaces that were sound at baseline. Among those sound surfaces, maxillary anterior facials received most caries-preventive benefit.

Agresti A: Categorical Data Analysis, ed 2. Hoboken, Wiley & Sons, 2002.
American Academy of Pediatric Dentistry (AAPD): Guideline on caries-risk assessment and management for infants, children, and adolescents. 2010. Available at: http://www.aapd.org/media/Policies_Guidelines/G_CariesRiskAssessment.pdf (accessed July 7, 2011).
Antunes JL, Narvai PC, Nugent ZJ: Measuring inequalities in the distribution of dental caries. Community Dent Oral Epidemiol 2004;32:41–48.
Azarpazhooh A, Main PA: Fluoride varnish in the prevention of dental caries in children and adolescents: a systematic review. J Can Dent Assoc 2008;74:73–79.
Backer Dirks O, Houwink B, Kwant GW: Some special features of the caries preventive effect of water-fluoridation. Arch Oral Biol 1961;4:187–192.
Beck JD, Lawrence HP, Koch GG: A method for adjusting caries increments for reversals due to examiner misclassification. Community Dent Oral Epidemiol 1995;23:321–330.
Bell RM, Klein SP: Management and evaluation of the effects of misclassification in a controlled clinical trial. J Dent Res 1984;63:731–735.
Brown LJ, Kaste LM, Selwitz RH, Furman LJ: Dental caries and sealant usage in U.S. children, 1988–1991: selected findings from the Third National Health and Nutrition Examination Survey. J Am Dent Assoc 1996;127:335–343.
Campbell MK, Elbourne DR, Altman DG; CONSORT group: CONSORT statement: extension to cluster randomised trials. BMJ 2004;328:702–708.
Candeli A, Scavizzi F, Marci F: The relationship between fluoride concentration and the caries frequency of different tooth surfaces in a high fluoride area. Caries Res 1970;4:69–77.
Carey V, Zeger SL, Diggle P: Modelling multivariate binary data with alternating logistic regressions. Biometrika 1993;80:517–526.
Casamassimo PS, Thikkurissy S, Edelstein BL, Maiorini E: Beyond the dmft: the human and economic cost of early childhood caries. J Am Dent Assoc 2009;140:650–657.
Crall JJ: Optimising oral health throughout childhood: the importance of caries risk assessment and strategic interventions. Int Dent J 2007;57:221–226.
DePaola PF: Measurement issues in the epidemiology of dental caries; in Bader JD (ed): Risk Assessment in Dentistry. University of North Carolina-Chapel Hill, Dental Ecology, 1990, pp 19–26.
Ellwood RP, O’Mullane D: The association between developmental enamel defects and caries in populations with and without fluoride in their drinking water. J Public Health Dent 1996;56:76–80.
Farsi N: Developmental enamel defects and their association with dental caries in preschoolers in Jeddah, Saudi Arabia. Oral Health Prev Dent 2010;8:85–92.
Featherstone JD: The science and practice of caries prevention. J Am Dent Assoc 2000;131:887–899.
Featherstone JD: Remineralization, the natural caries repair process – the need for new approaches. Adv Dent Res 2009;21:4–7.
Greenland S, Rothman KJ: Introduction to stratified analysis; in Rothman KJ, Greenland S, Lash TL (eds): Modern Epidemiology. New York, Lippincott, Williams & Wilkins, 2008, pp 258–282.
Hillson S, Bond S: Relationship of enamel hypoplasia to the pattern of tooth crown growth: a discussion. Am J Phys Anthropol 1997;104:89–103.
Hong L, Levy SM, Warren JJ, Broffitt B: Association between enamel hypoplasia and dental caries in primary second molars: a cohort study. Caries Res 2009;43:345–353.
Horowitz HS, Baume LJ, Dirks OB, Davies GN, Slack GL: Principal requirements for controlled clinical trials of caries preventive agents and procedures. Int Dent J 1973;23:506–529.
Ismail AI, Lim S, Sohn W: A transition scoring system of caries increment with adjustment of reversals in longitudinal study: evaluation using primary tooth surface data. Community Dent Oral Epidemiol 2011;39:61–68.
Koch G, Petersson LG: Caries preventive effect of a fluoride-containing varnish (Duraphat) after 1 year’s study. Community Dent Oral Epidemiol 1975;3:262–266.
Marinho VC: Cochrane reviews of randomized trials of fluoride therapies for preventing dental caries. Eur Arch Paediatr Dent 2009;10:183–191.
Marinho VC, Higgins JP, Logan S, Sheiham A: Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database Syst Rev 2002;3:CD002279.
Meurman PK, Pienihäkkinen K: Factors associated with caries increment: a longitudinal study from 18 months to 5 years of age. Caries Res 2010;44:519–524.
Milgrom P, Riedy CA, Weinstein P, Tanner AC, Manibusan L, Bruss J: Dental caries and its relationship to bacterial infection, hypoplasia, diet, and oral hygiene in 6- to 36-month-old children. Community Dent Oral Epidemiol 2000;28:295–306.
Nelson S, Albert JM, Lombardi G, Wishnek S, Asaad G, Kirchner HL, Singer LT: Dental caries and enamel defects in very low birth weight adolescents. Caries Res 2010;44:509–518.
Lai PY, Seow WK, Tudehope DI, Rogers Y: Enamel hypoplasia and dental caries in very-low birthweight children: a case-controlled, longitudinal study. Pediatr Dent 1997;19:42–49.
Lawrence HP, Binguis D, Douglas J, McKeown L, Switzer B, Figueiredo R, Laporte A: A 2-year community-randomized controlled trial of fluoride varnish to prevent early childhood caries in Aboriginal children. Community Dent Oral Epidemiol 2008;36:503–516.
Li Y, Navia JM, Bian JY: Caries experience in deciduous dentition of rural Chinese children 3–5 years old in relation to the presence or absence of enamel hypoplasia. Caries Res 1996;30:8–15.
Li Y, Navia JM, Caufield PW: Colonization by mutans streptococci in the mouths of 3- and 4-year-old Chinese children with or without enamel hypoplasia. Arch Oral Biol 1994;39:1057–1062.
Lin X, Wu W, Zhang C, Lo EC, Chu CH, Dissanayaka WL: Prevalence and distribution of developmental enamel defects in children with cerebral palsy in Beijing, China. Int J Paediatr Dent 2011;21:23–28.
McDonald SP, Sheiham A: The distribution of caries on different tooth surfaces at varying levels of caries – a compilation of data from 18 previous studies. Community Dent Health 1992;9:39–48.
Oliveira AF, Chaves AM, Rosenblatt A: The influence of enamel defects on the development of early childhood caries in a population with low socioeconomic status: a longitudinal study. Caries Res 2006;40:296–302.
O’Sullivan DM, Tinanoff N: Maxillary anterior caries associated with increased caries risk in other primary teeth. J Dent Res 1993;72:1577–1580.
Petersen PE, Bourgeois D, Ogawa H, Estupinan-Day S, Ndiaye C: The global burden of oral diseases and risks to oral health. Bull World Health Organ 2005;83:661–669.
Pine CM, Adair PM, Petersen PE, Douglass C, Burnside G, Nicoll AD, Gillett A, Anderson R, Beighton D, Jin-You B, Broukal Z, Brown JP, Chestnutt IG, Declerck D, Devine D, Espelid I, Falcolini G, Ping FX, Freeman R, Gibbons D, Gugushe T, Harris R, Kirkham J, Lo EC, Marsh P, Maupomé G, Naidoo S, Ramos-Gomez F, Sutton BK, Williams S: Developing explanatory models of health inequalities in childhood dental caries. Community Dent Health 2004;21:86–95.
Pitts NB: Inequalities in children’s caries experience: the nature and size of the UK problem. Community Dent Health 1998;15:296–300.
Preisser JS, Arcury TA, Quandt SA: Detecting patterns of occupational illness clustering with alternating logistic regressions applied to longitudinal data. Am J Epidemiol 2003;158:495–501.
Psoter WJ, Zhang H, Pendrys DG, Morse DE, Mayne ST: Classification of dental caries patterns in the primary dentition: a multidimensional scaling analysis. Community Dent Oral Epidemiol 2003;31:231–238.
Rethman J: Trends in preventive care: caries risk assessment and indications for sealants. J Am Dent Assoc 2000;131:8S–12S.
Ripa LW, Leske GS, Sposato A: The surface-specific caries pattern of participants in a school-based fluoride mouthrinsing program with implications for the use of sealants. J Public Health Dent 1985;45:90–94.
Roberts-Thomson KF, Slade GD, Bailie RS, Endean C, Simmons B, Leach AJ, Raye I, Morris PS: A comprehensive approach to health promotion for the reduction of dental caries in remote Indigenous Australian children: a clustered randomized controlled trial. Int Dent J 2010;60:245–249.
Selwitz RH, Ismail AI, Pitts NB: Dental caries. Lancet 2007;369:51–59.
Seow WK: Clinical diagnosis of enamel defects: pitfalls and practical guidelines. Int Dent J 1997;47:173–182.
Seow WK, Clifford H, Battistutta D, Morawska A, Holcombe T: Case-control study of early childhood caries in Australia. Caries Res 2009;43:25–35.
Shaffer JR, Wang X, Desensi RS, Wendell S, Weyant RJ, Cuenco KT, Crout R, McNeil DW, Marazita ML: Genetic susceptibility to dental caries on pit and fissure and smooth surfaces. Caries Res 2012;46:38–46.
Slade GD, Bailie RS, Roberts-Thomson K, Leach AJ, Raye I, Endean C, Simmons B, Morris P: Effect of health promotion and fluoride varnish on dental caries among Australian Aboriginal children: results from a community-randomized controlled trial. Community Dent Oral Epidemiol 2011;39:29–43.
Slade GD, Caplan DJ: Impact of analytic conventions on outcome measures in two longitudinal studies of dental caries. Community Dent Oral Epidemiol 2000;28:202–210.
Slayton RL, Warren JJ, Kanellis MJ, Levy SM, Islam M: Prevalence of enamel hypoplasia and isolated opacities in the primary dentition. Pediatr Dent 2001;23:32–36.
Targino A, Rosenblatt A, Oliveira A, Chaves A, Santos V: The relationship of enamel defects and caries: a cohort study. Oral Dis 2011;17:420–426.
ten Cate JM: Current concepts on the theories of the mechanism of action of fluoride. Acta Odontol Scand 1999;57:325–329.
Tewari A, Chawla HS, Utreja A: Comparative evaluation of the role of NaF, APF and Duraphat topical fluoride applications in the prevention of dental caries – a 2 1/2 years study. J Indian Soc Pedod Prev Dent 1991;8:28–35.
Velló MA, Martínez-Costa C, Catalá M, Fons J, Brines J, Guijarro-Martínez R: Prenatal and neonatal risk factors for the development of enamel defects in low birth weight children. Oral Dis 2010;16:257–262.
Weintraub JA, Ramos-Gomez F, Jue B, Shain S, Hoover CI, Featherstone JD, Gansky SA: Fluoride varnish efficacy in preventing early childhood caries. J Dent Res 2006;85:172–176.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.