Summary of findings 4. Fluoride toothpaste with higher versus lower concentration of fluoride for preventing caries in adults (mature permanent dentition).

The effects of fluoride toothpaste with higher versus lower concentration of fluoride for preventing caries in adults
Population: adults aged between 18 and 93 years of age at the start of the study Setting: home Intervention: toothbrushing with higher fluoride toothpaste concentration Comparison: toothbrushing with lower fluoride toothpaste concentration Outcomes: mature permanent dentition: D(M)FS, D(M)FT, proportion of adults developing new caries, adverse effects of toothpaste
Comparison	Outcomes	Anticipated absolute effects* (95% CI)		Relative effect (95% CI)	Number of participants (studies)	Certainty of the evidence (GRADE)	Comments
		Risk with lower fluoride concentration toothpaste	Risk with higher concentration toothpaste
1000 or 1100 ppm F compared with 0 ppm F	Caries increment (surface index D3MFS) Follow‐up: 12 to 24 months	The mean caries increment with 0 ppm F ranged from 0.69 to 4.99 D3MFSa	The mean caries increment in the higher fluoride group was on average MD 0.53 lower (95% CI 1.02 lower to 0.04 lower)	‐	2162 (3 RCTs)	⊕⊕⊕⊝ moderateb	Mean caries increment in the higher fluoride group was on average SMD 0.17 lower (95% CI 0.29 lower to 0.06 lower)
1000 or 1100 ppm F compared with 0 ppm F	Caries increment (tooth index D3MFT) Follow‐up: 24 months	The mean value with 0 ppm F was 1.52 D3MFTc	The mean caries increment in the higher fluoride group was on average MD 0.46 lower (95% CI 0.93 lower to 0.01 higher)	‐	247 (1 RCT)	⊕⊕⊝⊝ lowd	Mean caries increment in the higher fluoride group was on average SMD 0.24 lower (95% CI 0.49 lower to 0.01 higher)
1000 or 1100 ppm F compared with 0 ppm F	Proportion of adults developing new caries	No studies reported this outcome
1000 or 1100 ppm F compared with 0 ppm F	Adverse effects of toothpaste	No studies reported this outcome
*The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; D(M)FS: decayed, missing, filled surfaces (permanent dentition); D(M)FT: decayed, missing, filled teeth (permanent dentition); D3: dentinal/cavitated caries lesions level; F: fluoride; MD: difference in means; ppm: parts per million; RCT: randomised controlled trial; SMD: standardised mean difference.
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.

^aReported mean caries increment D₃MFS in the 0 ppm F groups. Caries increment D₃MFS values in 1 study were considerably higher than in the other 2 studies.
 ^bDowngraded for study limitations (high overall risk of bias due to high levels of attrition in 1 study). Despite substantial heterogeneity (I² = 68%) being observed for this comparison we did not downgrade for inconsistency, as all studies were showing a beneficial effect of the higher fluoride concentration.
 ^cReported mean caries increment D₃MFT in the 0 ppm F group.
 ^dDowngraded for study limitations (high overall risk of bias due to high levels of attrition) and imprecision.