Professionally applied Fluoride Paint-On Solutions (PAFS): Closing the Gaps in the Evidence Base for the Appropriate Use of Topical Fluorides

PhDAims To identify the gaps in the evidence-base for topical fluoride therapies (TFT) for caries and, to assess the effectiveness, safety and economic value of paint-on fluoride solutions (PAFS) for caries control. Methods Three studies were sequentially done: an overview of all existing TFT systematic reviews; a Cochrane systematic review of the effects of PAFS on caries where random-effects meta-analysis were performed; an economic-modelling study of PAFS in the context of Pakistan. Results TFT systematic reviews (N = 38) showed a lack of reviews addressing the effectiveness of PAFS or fluoride foams, comparisons with various fluoride agents and the use of caries arrest/reversal, costs, and patient reported outcomes. Reporting of methodological aspects was inadequate, except for Cochrane reviews. The Cochrane review showed that PAFS prevented 32% (95%CI 23% to 40%) more D(M)FS than placebo or no treatment. PAFS were not significantly more effective than fluoride gels or less effective than varnishes. PAFS arrested caries in deciduous dentition (SMD 0.39; 95%CI 0.17 to 0.60) and did not significantly cause more discomfort than placebo. No evidence was found on the relative economic value of PAFS. In the decision-modelling study, to save one tooth in Pakistan, annual PAFS applications were more cost-effective than annual fluoride varnish applications (ICER*=PKR 5174) but compared to the current situation PAFS still need an investment (ICER=PKR 873). Conclusions For topical fluoride, evidence-synthesis is still needed for fluoride foams, the relative value of TFTs against each other and other caries-preventive therapies. PAFS have a caries-reducing effect in children/adolescents and a caries-arresting effect in deciduous teeth. PAFS appear as effective as TFT gels and varnishes but there is insufficient evidence for relative efficacy and economic value against other topical fluorides. PAFS have superior costs-effectiveness compared with fluoride varnish, from the Pakistani public-payer perspective, but need investment when compared with current no-treatment