This article is written in pursuance of professional duty so that people may adopt healthy habits and lifestyles consistent with evidence-based scientific truth rather than being beguiled and deceived by false propaganda, media hype and advertising. It is now a well established scientifically proven incontrovertible fact that cleaning the teeth daily with a fluoride toothpaste plays a significant role in the prevention of dental caries. Consequently, the apparently increasing market share of non-fluoride toothpastes sold in Sri Lanka is cause for concern. For example, it would seem that the market share of one brand of toothpaste that does not contain fluoride has increased from 3.5 percent to 14 percent between 2013 and 2017.
We must not forget that even allowing for changes in oral disease patterns worldwide, dental caries (i.e., cavities in teeth) continues to be one of the commonest diseases in the world. Though not life threatening, it is potentially an extremely painful disease with the potential to ruin quality of life by making chewing difficult and spoiling the enjoyment of food, along with disastrous effects on facial appearance when the front teeth are affected. The social impact of dental disease in children is such that 51 million schooldays are lost to dental related illness every year!
No doubt, throughout the ages, treatment of the disease has made many dentists rich and prosperous especially with the availability of increasingly complex highly remunerative restorative therapies and modern technologies. On the other hand, countless patients worldwide will testify to the intolerable burden of high treatment costs, quite apart from the ravages of the disease and the discomfort of treatment that may involve prolonged stressful periods lying in a dental chair with the mouth open!
According to the World Health Organization, worldwide, 60–90 percent of schoolchildren and nearly 100 percent of adults have dental cavities. In Sri Lanka, 60 percent of six year olds have dental caries. The prevalence in 12 and 35–44 year olds is estimated to be around 30 percent and 80 percent respectively. Few diseases in the world have such a high prevalence. And to make matters worse, a review of epidemiological data from many countries in 2009 suggested that there might be a marked increase in prevalence taking place worldwide.
And yet dental caries is almost totally preventable with the combination of the simplest of methods including a lifelong low sugar diet, daily brushing with a fluoridated toothpaste, and the maintenance of good oral hygiene. That the disease continues to be a public health problem reflects public ignorance. But it is hard to escape the conclusion that there must also be a degree of professional indolence and indifference even at the highest levels where the eagerness to treat the disease is not matched by passion to prevent it.
It is against this background that any trend towards the aggressive marketing and popularisation of non-fluoride toothpastes in Sri Lanka must be seen as retrogressive and harmful to dental health. It runs contrary to the scientific imperative to do exactly the opposite and aim for 100 percent daily use of a fluoride toothpaste by the Sri Lankan population. A few examples will suffice to show the overwhelming scientific evidence and universal expert endorsement supporting the daily use of a fluoride containing toothpaste:
1. Following a review of 74 studies of fluoride toothpaste for the prestigious Cochrane Database of Systematic Reviews in 2003, the authors concluded that “fluoride toothpastes have been widely used for over three decades and remain a benchmark intervention for the prevention of dental caries. Supported by more than half a century of research, the benefits of fluoride toothpastes are firmly established. Children who brush their teeth at least once a day with a toothpaste that contains fluoride will have less tooth decay.”
2. A World Health Organization (WHO) Expert Committee as far back as 1984 concluded that “routine use of fluoride dentifrices is recommended practically everywhere, except for young children living in areas of endemic fluorosis” and that the findings of over 100 clinical trials indicate that fluoridated toothpastes reduces cavities by 20–30 percent. According to distinguished scientists who in 2004 reviewed the WHO approach for the prevention of dental caries in the 21st century, “WHO recommends that every effort must be made to develop affordable fluoride toothpastes for use in developing countries.” They even went on to say that accordingly, it would be in the best interests of countries to exempt fluoride toothpastes from all duties and taxes imposed on cosmetics.
3. The General Assembly of the International Dental Federation (FDI) in a resolution first adopted in 2000 and modified in 2018, affirmed that “regular use of fluoride toothpaste is scientifically recognised as a major means to reduce the prevalence and severity of dental caries and delay its onset in the global population,” and urged all countries to recognise the importance of providing universal access to fluoride toothpaste to fight dental caries.
4. In the UK, Public Health England, an agency of the Department of Health, in its 2017 “Evidence based Toolkit” for the prevention of dental disease, advocated the appropriate use of fluoride toothpaste at least twice daily in adults as well as in children from the moment the teeth erupt into the mouth.
5. One of the most significant transformations in disease patterns in the history of medical epidemiology was the dramatic decline of dental caries in industrialised countries in the latter half of the 20th century, with reductions in lifetime caries experience exceeding 75 percent. While there have been differing opinions about the reasons for this decline, an opinion survey of 52 selected experts in the mid 1990s showed that the daily, if not twice daily use of fluoridated toothpaste was considered to be the most important single factor by most experts.
The above represent a small sample of the monumental scientific evidence and unanimous expert opinion validating the twice daily use of a fluoride toothpaste for the prevention of dental caries. Accordingly, it is not surprising that in many countries fluoride toothpastes make up more than 95 percent of toothpaste sales, whatever the brand.
But it would be surprising and indeed ominous if as seems to be the case in Sri Lanka there is an opposite trend towards using non-fluoridated toothpastes to clean the teeth! That there seems to have been so little reaction to such adverse trends that are a travesty of the scientific evidence and a danger to dental health may reflect poorly on the dental profession in Sri Lanka.
There are nowadays more dentists, more dental consultants, more dental administrators, more dental academics, and more dental professional organisations than ever before. Given such a large and influential dental establishment, one would expect the proliferation of non-fluoridated toothpastes to be bitterly resisted and opposed by the dental profession. On the contrary, it is sad to note that a few years ago a leading dental professional organisation actually signed an MOU with a commercial organisation endorsing a toothpaste that does not contain fluoride!
Furthermore, the aggressive marketing of non-fluoride toothpaste carries the deceptive insinuation that such products are efficacious in preventing dental caries.
In creating this impression advertisers fall back on some limited investigations (seemingly funded by the manufacturers themselves) and published in a local journal.
Even so, the results from these studies are confined to demonstrating the effects of the non-fluoride toothpaste tested not on dental caries, but on bacterial plaque and gum disease – and even that, over a very limited study duration!
To imply from these results that such products have any advantage whatsoever over a standard fluoride toothpaste in reducing dental caries would be dishonest, especially as dental caries is a sugar-related disease where demonstrating the anti-caries effect of any new toothpaste necessitates a rigorous three-year randomised controlled clinical trial.
In anticipation of such potential misinterpretation by commercial interests, one would have wished that the ensuing publications might have carried an unequivocal clarification to the effect that the results should in no way be interpreted to mean that the toothpaste being tested had any cariostatic benefit whatsoever.
As a contribution to public education, this article has reiterated the solid scientific evidence base supporting lifelong twice-daily tooth cleaning with a fluoridated toothpaste for the prevention of cavities in teeth.
Hopefully, it would also trouble the conscience of self-satisfied dental professionals, their pompous organisations and others in the health sector, motivating them to resolutely pursue the goal of 100 percent population utilisation of a fluoridated toothpaste, in the grim struggle to control one of the most prevalent chronic diseases in the world.
Add new comment