Efficacy Of Tooth Mousse: Authors' Reply

Abstract

We appreciate Associate Professor Evans having taken the time to provide his personal views on Tooth Mousse and to also comment on the Therapeutic Guidelines, a publication authored by an expert group which is then examined closely before being endorsed by other authorities. While not immediately relevant to our recent ADJ paper,1 it is noteworthy that the interest in this area of CPP-ACP technology is reflected in significant publications – and not only for caries prevention but for other discrete clinical applications, including desensitizing dentine and reversing white spot lesions (applications for which there is evidence from randomized clinical trials). The clinical use of CPP-ACP technology is supported by a large body of literature including a number of systematic reviews. A 2009 meta-analysis identified more than 120 journal articles on CPP-ACP technology, which included animal model studies, in situ clinical studies, and randomized clinical trials, many of which were on the use of Tooth Mousse/MI Paste. A 2012 textbook chapter authored from our group identified that by the end of 2010, nine clinical trials of Tooth Mousse had been conducted across a range of locations around the globe which had shown regression of white spot lesions. Other studies have shown benefits in terms of caries reversal, caries prevention and altered plaque ecology in patients undergoing fixed orthodontic treatment,2-7 results which are consistent with our current understanding of the various mechanisms by which Tooth Mousse affects the ionic and microbial aspects of the oral environment in young children – and which is the context within which the sentence about Tooth Mousse and caries prevention referred to is placed within our ADJ paper.1 The finer points of discussion around what effects one sees in terms of caries prevention with Tooth Mousse in children we have made in the accompanying response to Associate Professor Kilpatrick wherein we explain the components of the Logan clinical trials which showed benefits, and the large positive effects of parallel interventions. There is considerable interest around the globe in the potential for caries prevention from using Tooth Mousse in young children and in older children its fluoride-containing relative Tooth Mousse Plus. We certainly stand by our views that there are benefits to using Tooth Mousse in young children, but stress that one should not depend entirely on the daily use of one agent, be that fluoride toothpaste or Tooth Mousse, to control early childhood caries – rather a much broader approach to prevention is needed where the benefits of several positive interventions are combined – as was the case the group of Logan studies which we cited. We expect that over time more will be learnt about the benefits or not of combining various preventive approaches. Certainly there is evidence from clinical trials of benefits of Tooth Mousse even in patients who are already using fluoride toothpastes and who are receiving supervised fluoride mouthrinses,8 and published literature showing that Tooth Mousse with fluoride is superior to fluoride alone. From time to time we see trials on various preventive agents including Tooth Mousse presented at meetings or published with suboptimal or negative results because of what we would regard as incorrect application protocols. For example, in the Thai study mentioned by Associate Professor Evans, the investigators treated the Tooth Mousse crème like fluoride toothpaste and the subjects used 0.4 gram once per day, which is suboptimal because in a high risk group they should have been using at least 1 gram twice daily after brushing with a fluoride toothpaste. Our final caveat to add to the comments of Associate Professor Evans is the need for readers to look carefully at the finer details of the protocol used for any trial of a preventive product and consider what confounding effects could be occurring. An excellent example is seen in the Thai study mentioned, where the two groups are not equally matched for caries risk factors. The authors of that paper state in their discussion that the children in the Tooth Mousse group fell asleep significantly more often on the bottle than the control group, which would have placed them at greater risk of caries development.