10.59987/ads/2015.1.1-5
Aim. Doing a meta-analysis to answer the question: “Does fluoride tablets prevent dental caries among children and adolescents?”
Materials and methods. A review of the literature is performed using the following databases: PubMed, Embase, CINAHL, Cochrane Library, Embase, NHS Evidence Oral Health, PsycINFO, Web of Knowledge, Metalib. The keywords used are dental fluoride, fluoride tablets. The studies analyzed was limited to English language with free abstract. For the studies selection was taken into consideration the criteria proposed by the Cochrane Oral Health Group.
Results. Few studies with good quality were identified in general. Only 3 out of 779 studies were acceptable.
Conclusions. Evident disagreements among the results show that there’s a limited effectiveness on fluoride tablets.
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1971-1441
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en
N. Zerman 
https://creativecommons.org/licenses/by-nc-nd/4.0
Annali di stomatologia
dental fluoride
The role of fluoride tablets in the prophylaxis of dental caries. A literature review
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Review article
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2022-08-12
2015-03-01
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Ann Stomatol (Roma)
N. Zerman 
2015
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1971-1441
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dental fluoride
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The role of fluoride tablets in the prophylaxis of dental caries. A literature review
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                                                                                                       Review article



    The role of fluoride tablets in the prophylaxis
    of dental caries. A literature review




                                                                                                         i
                                                                                                       al
                                                                                                    on
    Lisa Tomasin, DDS                                            better to replace this practice with other prevention
    Luca Pusinanti, DDS                                          methods.
    Nicoletta Zerman, MD, SDS                                    A literature review was done to answer the question:
                                                                 Do fluoride tablets prevent dental caries among chil-
                                                                 dren and adolescents?




                                                                                           zi
    Department of Pediatric Dentistry, Dental School,
    University of Verona, Italy
                                                                 Materials and methods




                                                                              na
    Corresponding author:                                        A review of the existing literature edited in English
    Lisa Tomasin                                                 has been performed using the following databases:
    Department of Pediatric Dentistry, Dental School,            PubMed, CINAHL, Cochrane Library, Embase, NHS
    University of Verona, Policlinico G.B. Rossi




                                                                   er
                                                                 Evidence Oral Health, PsycINFO, Web of Knowledge,
    P.le L.A. Scuro, 10                                          Metalib. The keywords used have been: dental fluo-
    37134 Verona, Italy                                          ride, fluoride tablets.
    E-mail: nicoletta.zerman@univr.it                            The objective is to evaluate the effects of the ingestion



                                                           t     of fluoride supplements in the form of tablets (chew-

    Summary
                                                        In       able or not) for preventing dental caries in children.
                                                                 Do fluoride tablets prevent dental caries among chil-
                                                                 dren and adolescents?
    Aim. Doing a meta-analysis to answer the ques-               The studies selection process has been conducted
    tion: “Does fluoride tablets prevent dental caries           according to the Cochrane Oral Health Group criteria
                                               ni
    among children and adolescents?”                             described in detail by Tubert-Jeannin et al. in 2009
    Materials and methods. A review of the literature            (1); according to these criteria only randomized con-
    is performed using the following databases:                  trolled clinical trials (RCTs) with randomization at the
                                     io

    PubMed, Embase, CINAHL, Cochrane Library, Em-                level of the child or at the level of a group have been
    base, NHS Evidence Oral Health, PsycINFO, Web                analyzed.
    of Knowledge, Metalib. The keywords used are                 Other study designs as non-randomized controlled
    dental fluoride, fluoride tablets. The studies ana-          clinical trials, prospective cohort studies, historical
                           iz



    lyzed was limited to English language with free              control studies and retrospective epidemiological
    abstract. For the studies selection was taken into           studies have been excluded. Studies with an inter-
    consideration the criteria proposed by the                   vention or follow-up period of less than 2 years have
           Ed




    Cochrane Oral Health Group.                                  been excluded as well. Studies where the active in-
    Results. Few studies with good quality were iden-            tervention consisted of any other systemically deliv-
    tified in general. Only 3 out of 779 studies were            ered fluoride (water, milk, salt) provided in addition to
    acceptable.                                                  fluoride supplements have been excluded.
    Conclusions. Evident disagreements among the                 Studies in which a topical fluoride based measure or
    results show that there’s a limited effectiveness            a non-fluoride based preventive measure applied in a
IC




    on fluoride tablets.                                         control group was different from the one administered
                                                                 in the intervention group (in addition to fluoride sup-
    Key words: fluoride tablets, dental fluoride.                plements) have been excluded.
                                                                 Surveys reporting only on changes in plaque, fluoride
C




                                                                 uptake by enamel or dentin or fluoride salivary secre-
    Introduction                                                 tion have been excluded.
                                                                 Children or adolescents aged 16 or less at the start of
    The prophylaxis with fluoride tablets represents an in-      the study have been included (irrespective of initial
©




    teresting topic for dentists because there are ques-         level of dental caries, background exposure to fluo-
    tions still remain open.                                     rides, dental treatment level, nationality, setting
    In view of recommendations and national and interna-         where intervention is received or time when it start-
    tional guidelines that clear the doubts on the issue,        ed). Older participants have been excluded to avoid
    the practical problem consists in understanding how          the selection of studies concerning the use of fluoride
    useful it is to suggest the use of fluoride supplements      supplements to prevent root caries or to improve
    to patients, in which quantity and time-frame, or if it is   bone density.

    Annali di Stomatologia 2015; VI (1): 1-5                                                                            1
    L. Tomasin et al.


    Types of interventions                                           Dental fluorosis has to be assessed with a specific in-
                                                                     dex and any other possible negative effects has to be
    Ingestion of fluoride tablets, with or without the use           sought.
    of vitamins, at any concentration, amount, frequency             For each RCT the following data will be recorded:
    of use, duration of application, and with any tech-              • Author(s), year of publication, number of reports




                                                                                                               i
    nique of application (sucked or not, chewed or not,                 on the study, country.




                                                                                                             al
    diluted or not before being swallowed, with or without           • Methods: study design, research objective, study
    the use of topical fluoride based measures) has been                duration, randomization, unit (individual/cluster),
    evaluated.                                                          comparability of baseline characteristics, blind-




                                                                                                          on
    The control group has to be formed by children who                  ness of participants, blindness in outcome assess-
    have not taken fluoride supplement or have ingested                 ment, reliability of primary outcome measurement,
    a placebo supplement (with or without the use of vita-              co-intervention and/or contamination, institutions
    mins), subjected to topical fluoride based measures                 and manufacturers involved, local characteristics.
    as topical fluoride application, fluoride varnish or fluo-       • Participants: setting where participants were re-




                                                                                                 zi
    ride tooth paste or not undergone topical fluoride                  cruited, criteria for inclusion, demographic charac-
    based measures but who have undergone non-fluo-                     teristics (age, gender, socio-economical status),
    ride based measure (chlorexidine, xylitol, sealants,                caries severity, exposure to fluoride, number at




                                                                                    na
    oral hygiene interventions, etc.).                                  start and at the end of the study.
                                                                     • Intervention: tablets, treatment duration and appli-
                                                                        cation frequency, fluoride doses, combination of
    Assessment parameters                                               methods, compliance (supervision of partici-




                                                                        er
                                                                        pants).
    For permanent and deciduous dentition, changes in                • Details of the outcomes: method of assessment
    caries increment, as measured by the difference be-                 (clinical/radiographic), mean duration of study.
    tween the number of decayed, missing and filled                  • Measures: units measured (tooth/surface), index
    teeth (dmft/DMFT) or surfaces (dmfs/DMFS) at base-


                                                             t          used (DMFT/S), types of tooth/surface considered
    line and at the time of final evaluation for the same
    children.
                                                          In            (deciduous, permanent).
                                                                     • Adverse effects – fluorosis – is recorded.
    DMFT (Decayed, Missing, Filled Teeth) is determined
    by calculating the number of decayed, reconstructed
    or extracted permanent elements in a patient com-                Results
                                             ni
    pared with the total number of present teeth (general-
    ly 28 in the permanent dentition, excluding the third            Many studies were identified, among which 3 have
    molars). The dmft refers to the deciduous dentition.             been judged usable and these have subsequently
                                  io

    The DMFS/dmfs considers the teeth surfaces as well.              been analyzed in detail (Tab. 1).
    The difference in the caries incidence in permanent
    and deciduous dentition is measured this way in the
    treatment and control groups (if the groups are com-             Discussion
                         iz



    parable at baseline).
    The method of assessment executed has been record-               According to Limeback and other Authors weak sci-
    ed (clinical and radiographic).                                  entific evidence support the effectiveness of fluoride
          Ed




    Adverse effects will be recorded and noted.                      supplements (2-5).

    Table 1. Studies considered for the review.

    Author                Study      Patient              Intervention/control group     Results (>DMFS)        Side effects
                          type       characteristics
IC




    Driscoll WS,          RCT        Mean age             APF (acidulated                7.70                   Not investigated
    Heifetz SB,           DB         6.6 yr.              phosphate-fluoride)
    Brunelle JA.                                          tablet daily dosage 1 mg F.
    1979                                                  Daily dosage APF 2 mg F.       7.64
C




    USA                                                   Placebo tablets.               11.53
    Lin YT,               RCT        22-26-month-old      Daily NaF tablet 0.25 mg F.    4.10                   Not investigated
    Tsai CL.                         children with        No fluoride supplement.        8.35
    2000                             cleft lip and/or
©




    Taiwan                           palate.
    Stecksén-Blicks C,    RCT        10-12-year-old       Daily dose 2.5g xylitol in     2.7                    Not investigated
    Holgerson PL,                    children with        2 tablets x3 times daily.
    Twetman S.                       hight caries risk.   Xylitol as above but tablets
    2008                                                  did also contain 0.25 mg F.
    Sweden                DB                                                             2.7


    2                                                                                      Annali di Stomatologia 2015; VI (1): 1-5
    The role of fluoride tablets in the prophylaxis of dental caries. A literature review


    The American Center for Disease Control (CDC) also                 ed information on the adverse effects associated with
    has published in 2001 recommendations for using flu-               the use of fluoride supplements” (10).
    oride to prevent and control dental caries. They con-              Driscoll’s study of 1979 was conducted with children’s
    cluded that the quality of evidence to support use of              supervised intervention in school; tablets were not giv-
    fluoride supplements by children aged less than 6                  en in weekends, holidays, or vacations (max 145 days




                                                                                                                i
    years was low (6).                                                 with tablets per year). No radiographs were used in




                                                                                                              al
    The Swedish Council on Technology Assessment in                    the evaluation and to an objective analysis it seems
    Health Care has also conducted a systematic review                 that tablets are most effective in approximal surfaces.
    on the effectiveness of different measures for caries              The study was conducted in North Carolina, where the




                                                                                                           on
    prevention. Five studies related to the effect of fluo-            water fluoridation rate is lower than 0,03 ppm.
    ride supplements on permanent teeth were included                  The Author concludes recommending the use of fluo-
    in this review. The authors concluded that there was               ride tablets in schools in areas where there is no wa-
    no clear evidence that the use of fluoride supple-                 ter fluoridation (11).




                                                                                                  zi
    ments prevents dental caries on permanent teeth.                   In Lin’s study (12) 59 males and 56 females (22-26-
    They noticed that the only study that found a signifi-             month-old children with cleft lip and/or palate) were
    cant preventive effect of fluoride supplements was an              selected. The study was conducted in Taiwan, where




                                                                                     na
    old study conducted during the 70s (7).                            there is no water fluoridation. The test group was ad-
    Hasson et al., in 2008, examined evidence regarding                ministered with 0.25 mg of fluoride a day. After two
    the effectiveness of fluoride supplements in prevent-              years, the DMFS analysis results stated that children
    ing caries and their association with dental fluorosis.            taking F-tablets showed a borderline difference, not
    They concluded that “there is weak and inconsistent                statistically relevant compared to the control group (p




                                                                          er
    evidence that the use of fluoride supplements pre-                 = 0,065).
    vents dental caries in primary teeth. There is evi-                Children suffering from cleft lip and palate are, ac-
    dence that such supplements prevent caries in per-                 cording to Lin, considered individuals with a high-risk
    manent teeth. Mild-to-moderate dental fluorosis is a               of developing dental caries. As a matter of fact they
    significant side effect” (8).

                                                              t        have a high prevalence of S. Mutans from the age of
    In 2009 Espelid conducted a systematic review on
                                                           In          18 months. In the Author’s opinion it is important to
    the efficacy of fluoride tablets in dental caries pre-             establish an early dental health program and to ade-
    vention. He found 7 satisfying studies according to                quately inform parents in order to prevent potential
    the considered criteria. This happened because, un-                future problems.
    like in this study, he modified the criteria described             In Stecksèn-Blicks’s study, 160 children aged 10-12
                                               ni
    by Cochrane review (9).                                            years with high caries risk were selected and ran-
    However the Author resolved that “very few studies of              domly divided into two groups. The test group was
    good quality were identified in general” and that                  administered with xylitol (2.5 g) and fluoride (1.5 g) in
                                     io


    “there is limited evidence that F tablets are effective”           two tablets three times a day, while the control group
    hoping that there will be new, well-designed studies               was administered only with xylitol (2.5 g). Clinical as-
    within this field in the future.                                   sessment was followed by radiographic assessment.
                           iz



    Espelid classifies the studies we explored with a 1-               The compliance analysis showed that 29% of sub-
    level of evidence, meaning RCTs with a high risk of                jects rated as having poor compliance, 30% good
    bias. On the contrary, among the ones he identified                compliance and 41% excellent compliance.
           Ed




    only 2 are worth a 1+ level, being RCTs with a low                 The study results show that “no statistical significant
    risk of bias. However, in his opinion, these studies               difference in dental caries incidence can be found be-
    are very old.                                                      tween the two study groups (p > 0.05)”. The popula-
    The most recent review of the existing literature was              tion of this study developed an average DMFS of 2.7
    done by Tubert-Jeannin for the Cochrane Oral Health                during this 2-year study, among which the majority
    Group at the end of 2011. In their review the Authors              (1.8) were lesions to approximal surfaces.
IC




    took into account fluoride supplements in general                  The Author concludes that “the results of this 2 years
    (tablets, drops, lozenges and chewing gums). Only                  study do not support the administration of tablets con-
    11 out of the 7196 studies were considered accept-                 taining fluoride and xylitol for dental caries prevention
    able. The results of this review suggest that the use              among young adolescents with a high caries risk” (13).
C




    of fluoride supplements was associated with a reduc-               Burt stated as well that “little firm evidence exists for
    tion in DMFS between 95 and 16% in permanent                       the efficacy of dietary fluoride supplements when taken
    teeth. The effect of fluoride supplements was unclear              from birth or soon after” adding that “fluoride supple-
    on primary teeth. In one study, no caries-inhibiting ef-           ments are a risk factor for fluorosis” and that “the pre-
    fect was observed on deciduous teeth while, in anoth-              eruptive cariostatic benefits of fluoride are minor” (14).
©




    er study, the use of fluoride supplements was associ-              According to the Author, “fluoride supplements, when
    ated with a substantial reduction in caries increment.             ingested for a pre-eruptive effect by infants and young
    The Authors rated “10 trials as being at unclear risk              children, therefore carry more risk than benefit”.
    of bias and 1 at high risk of bias, and therefore the tri-         In the existing literature there are actually very few
    als provide weak evidence about the efficacy of fluo-              exceptions against the use of fluoride tablets, the ma-
    ride supplements”. Moreover the review found “limit-               jority support the administration of these supplements

    Annali di Stomatologia 2015; VI (1): 1-5                                                                                   3
    L. Tomasin et al.


    proving the benefits derived from consumption. Ac-            this reason, according to Burt, “fluoride supplements
    cording to Burt, design faults are common in these            should no longer be used for young children” (14).
    studies. Some of these problems, for example, can             In conclusion, only 3 studies met the inclusion criteria
    be found in a 1978 review where Burt noticed that the         and they show contrasting results: Driscoll supports
    studies took into account selected participants with-         the efficacy of fluoride tablets to prevent caries, Lin




                                                                                                                i
    out randomization and that there was no control               maintains that children in the test group presented a




                                                                                                              al
    group. According to this review prophylaxis with fluo-        borderline, but non-significant statistical difference
    ride tablets entails a caries reduction fluctuating be-       when compared with the control group, while Steck-
    tween 50 and 80% in the primary dentition and be-             sén-Blicks doesn’t find any reason for the utilization.




                                                                                                           on
    tween 20 and 40% in the permanent dentition (15).             Differences between the different study designs don’t
    Burt mentions other studies in which the design faults        help the comparison. For the same reason it is not
    are so serious that they can call the results validity in-    easy to increase the examined sample aggregating
    to question. For example, in a retrospective study,           different studies.
                                                                  F-doses as well are dissenting, this being an impor-




                                                                                                 zi
    Aasenden and Peebles (16) maintain an 80% reduc-
    tion in caries prevalence among children who were             tant start point for the evaluation of effects, given that
    administered with fluoride supplements from birth,            it is well known that the effect on caries prophylaxis is
                                                                  dose dependent.




                                                                                 na
    compared with children who didn’t take any. However
    in this study there was a serious mistake; children be-       Therefore, there is a limited evidence about fluoride
    longing to the group administered with fluoride were          tablets efficacy.
    not randomly chosen. Burt noticed that children be-           There is a need for new, well-designed studies within
    longing to this group turned out to have a decidedly          this field, taking into account possible negative ef-




                                                                    er
    better oral hygiene compared to the ones who were             fects as well, allowing a better search of advantages
    not taking any tablets and they were mainly females.          and disadvantages of this prophylaxis method.
    This fact, according to the author, is the reason of re-      Despite the fact that results discourage a systemic
    sults alteration (14).                                        and prenatal administration, this is still in use, show-



                                                            t
    According to Riordan it is difficult to conduct ethical and   ing low professional updating.
    adequate studies on fluoride supplements and on den-
                                                         In
    tal caries prevention (17). Studies should include a very
    high number of participants, given the continuous de-         References
    crease of dental caries prevalence; this raises consid-
                                                                   1. Tubert-Jeannin S, Tramini P, Gerbaud L, Amsallem E, Schulte
    erably the cost of the study (18). Moreover the testing
                                            ni
                                                                      A, Auclair C, Ismail A. Fluoride supplements (tablets, drops,
    should last long enough to allow caries to appear, but            lozenges or chewing gums) for preventing dental caries in
    this doesn’t happen often because of the population’s             children. Editorial Group: Cochrane Oral Health Group. Pub-
    mobility and because of many parents reluctance to                lished Online: 21 JAN 2009.
                                  io


    comply with the dosage schedule for an extended peri-          2. Limeback H, Ismail A, Banting D, DenBesten P, Feather-
    od of time. Furthermore, some individuals could leave             stone J, Riordan PJ. Canadian Consensus Conference on
    the study in long time scales. Riordan maintains that all         the appropriate use of fluoride supplements for the pre-
                         iz



    these variables can alter the testing results (17).               vention of dental caries in children. J Can Dent Assoc. 1998
    Only a few supplement studies have taken account of               Oct;64(9):636-9.
                                                                   3. Clark DC. Appropriate uses of fluorides for children: guide-
    factors such as socio-economic status or parent’s ed-
                                                                      lines from the Canadian Workshop on the Evaluation of Cur-
          Ed




    ucational level, but these studies suggest that such              rent Recommendations Concerning Fluorides. J Can Med
    variables are more important for caries prevention                Assoc. 1993;149:1787-93.
    than the use of supplements (19-21).                           4. Ismail A. Fluoride supplements: current effectiveness, side
    According to Spencer “fluoride can prevent caries up              effects and recommendations. Community Dent Oral Epi-
    to 71%” but just 2% of this reduction is due to the               demiol. 1994;22:164-72.
    contribution of tablets and the reasons for the low            5. Nojwack-Raymer R, Driscoll WS, Selwitz R, Li S-H, Heifetz
IC




    contribution of fluoride supplements were poor effica-            SB. A comparison of the caries preventive effects of fluo-
                                                                      ride mouth rinsing, fluoride tablets and both procedures com-
    cy in a time when caries incidence is low, and poor
                                                                      bined: final results after eight years. J Public Health Dent.
    compliance with recommendations to use it (22).
                                                                      1992;52;111-6.
    Therefore the statement of any preventive procedure            6. Centers for Disease Control and Prevention. Recommen-
C




    should occur, as much as possible, according to the               dations for using fluoride to prevent and control dental caries
    existence of clinical studies that meet given quality             in the United States. Morbidity and Mortality Weekly Report:
    criteria.                                                         Recommendation Report. 2001;50(RR-14):1-42.
    From this studies one can infer that while some pre-           7. The Swedish Council on technology assessment in health
    ventive benefits are possible, especially with regard             care. Prevention of dental caries. A systematic review. 2002;
©




    to topical action, the evidence of efficacy of fluoride           Vol. report n.161.
                                                                   8. Hasson H, Ismail A. Fluoride supplements, dental caries
    tablets used from birth or from childhood is not strong
                                                                      and fluorosis: a systematic review. J Am Dent Assoc. 2008;
    enough. Comparing risks and benefits the balance is               139(11):1457-68.
    against the use of this methodology because, as said           9. Espelid I. Caries preventive effect of fluoride in milk, salt
    before, fluoride has little effect on caries prevention           and tablets: a literature review. Eur Arch Paediatr Dent.
    but involves an evident risk for dental fluorosis. For            2009;10(3):149-56.


    4                                                                                      Annali di Stomatologia 2015; VI (1): 1-5
    The role of fluoride tablets in the prophylaxis of dental caries. A literature review


    10. Tubert-Jeannin S, Auclair C, Amsallem E, Tramini P, Ger-                   tion from birth on deciduous and permanent teeth. Arch Oral
        baud L, Ruffieux C, Schulte AG, Koch MJ, Rège-Walther M,                   BioI. 1974;19:321-6.
        Ismail A. Fluoride supplements (tablets, drops, lozenges or          17.   Riordan PJ. The place of fluoride supplements in caries pre-
        chewing gums) for preventing dental caries in children (Re-                vention today. Aust Dent J. 1996;41(5):335-42.
        view). The Cochrane Library. 2011, Issue 12.                         18.   O’Rourke CA, Attrill M, Holloway PJ. Cost appraisal of a flu-




                                                                                                                             i
    11. Driscoll WS, Heifetz SB, Brunnelle JA. Treatment and                       oride tablet program to Manchester primary schoolchildren.




                                                                                                                           al
        post-treatment effects of chewable fluoride tablets on den-                Community Dent Oral Epidemiol. 1988;16(6):341-4.
        tal caries: findings after 7 1/2 years. J Am Dent Assoc.             19.   Friis-Hasche E, Bergmann J, Wenzel A, et al. Dental health
        1979;99(5):817-21.                                                         status and attitudes to dental care in families participating
    12. Lin YT, Tsai CL. Comparative anti-caries effects of tablet and             in a Danish fluoride tablet program. Community Dent Oral




                                                                                                                        on
        liquid fluorides in cleft children. J Clin Dent. 2000;11(4):104-6.         Epidemiol. 1984;12:303-7.
    13. Stecksén-Blicks C, Holgerson PL, Twetman S. Effect of xyl-           20.   Kalsbeek H, Verrips GH, Backer Dirks O. Use of fluoride tablets
        itol and xylitol-fluoride elozenges on approximal caries de-               and effect on prevalence of dental caries and dental fluoro-
        velopment in high-caries-risk children. Int J Paediatr Dent.               sis. Community Dent Oral Epidemiol. 1992;20:241-5.
        2008;18(3):170-7.                                                    21.   Tijmstra T, Brinkman-Engels M, Groeneveld A. Effect of so-




                                                                                                             zi
    14. Burt BA. The case for eliminating the use of dietary fluoride              cioeconomic factors on the observed caries reduction after
        supplements for young children. J Public Health Dent. 1999                 fluoride tablet and fluoride toothpaste consumption. Com-
        Fall;59(4):269-74.                                                         munity Dent Oral Epidemiol. 1978;6:227-30.




                                                                                             na
    15. Binder K, Driscoll WS, Schutzmannsky G. Caries-preventive            22.   Spencer AJ. Contribution of fluoride vehicles to change in
        fluoride tablet programs. Caries Res. 1978;12:22-30.                       caries severity in Australian adolescents. Community Dent
    16. Aasenden R, Peebles TC. Effects of fluoride supplementa-                   Oral Epidemiol. 1986;14:238-41.




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    Annali di Stomatologia 2015; VI (1): 1-5                                                                                                    5
