Verniz fluoretado em pré-escolares: recomendações de uso e suas bases científicas

Abstract

The aim of this study was to critically evaluate the evidence and recommendations on the use of fluoride varnish (FV) for the prevention and control of caries in preschoolers (children up to 71 months old). Three separate studies were conducted. In the first study, two investigators independently searched for recommendations and clinical practice guidelines (CPG) on the use of FV in preschoolers in October of 2021. This search was conducted on the first five pages of Google Search™ and in three CPG databases Also independently, the evaluators selected and included official documents from government bodies or pediatric dentistry associations on the use of VF and extracted and recorded the data. A third evaluator resolved any discrepancies. Each CPG identified underwent evaluation using the AGREE II instrument. Twenty-nine documents were included, 23 recommendations and 6 CPG. The recommendations exhibited variability based on age, caries risk, and application frequency. Only one out of the six CPGs scored over 70% in the AGREE II overall assessment. In the second study, a review of systematic reviews (SR) was conducted, including SR, with or without meta-analyses, of randomized and quasi-randomized controlled trials assessing the use of FV for caries prevention in preschoolers compared to placebo, standard care, or no intervention. The search, conducted in March 2023, involved eight electronic databases. Two reviewers independently selected SR and extracted their data. The methodological quality (MQ), risk of bias (RB), and certainty of evidence (CE) were accessed using AMSTAR-2, ROBIS, and GRADE, respectively. Of the 13 SRs included, six presented insufficient evidence; five SRs concluded that VF is effective; and two SRs suggested irrelevant clinical benefit. MQ was assessed as high in one SR, low in two and critically low in 11 SR. The RB was considered low in three SR and high in ten. The synthesis and results domain of SR was the most frequently assessed as high risk. The CE ranged from moderate to very low, with RB being the criterion that most contributed to reducing it. Study three investigated the presence of spin in the abstracts of the SRs included in study two. Two independent investigators assessed the presence of spin in the 21 items of the Yavchitz et al. (2016) spin classification, divided into the categories of misleading reporting, misleading interpretation and inappropriate extrapolation. The spin severity ranking was used, categorizing high, medium and low according to their position in the ranking. Ten of the 13 SRs had at least one item with spin and four of these had at least one item of high severity. The most frequent category was misleading reporting. Spin was present in the majority of the SRs included. Currently, the application of fluoride varnish is widely recommended and the CPGs that recommend its use are of low quality. The evidence on the anti-caries benefit of FV diverges in its conclusions, has critically low quality, a high risk of bias and presents spin in its abstracts.