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Addressing Precavitated Lesions in Toddlers

I want to give a child the best chance of reversing the lesions with fluoride but I am concerned about exposing her to too much fluoride. What is the correct protocol?

QUESTION:  I work in a pediatric practice that serves a variety of at-risk and underserved populations. We recently had a 3-year-old girl come in for her first dental visit. Unfortunately, she presented with several precavitated caries lesions. I want to give this child the best chance of reversing the lesions with fluoride but I am concerned about exposing her to too much fluoride. What is the correct protocol?


I am glad you are concerned about fluoride exposure, as children age 18 months to 36 months are most susceptible to cosmetically objectionable fluorosis of their developing permanent dentition (Figure 1). As always, the risk-benefit ratio must be weighed. In this case, the risk of fluorosis for a 3-year old vs the benefits of a topical fluoride application to prevent the early lesions from progressing to cavitated lesions and possibly causing pain must be considered.

In 2013, the American Dental Association (ADA) Council on Scientific Affairs published evidence-based clinical recommendations regarding professionally applied and prescription-strength home-use topical fluoride agents for caries prevention.1 The recommendations include two types of professionally applied fluorides: 5% neutral sodium fluoride (NaF) varnish and 1.23% acidulated phosphate fluoride (APF) gel. However, for children younger than 6, only the 5% NaF varnish is recommended. This is due to the risk of adverse effects (particularly nausea and vomiting) associated with swallowing excess amounts of fluoride gel. Even though 5% NaF varnish contains a much higher concentration of fluoride (22,000 ppm) compared with the APF gel (9,000 ppm)—overall, less fluoride is used for a full-mouth application. This is because the varnish is painted on the teeth in a thin layer. In addition, evidence suggests that 5% NaF varnish can arrest active pit and fissure caries in primary teeth.2 Therefore, the topical fluoride of choice for this child is the 5% NaF varnish, which can be administered every 3 months to 6 months.

Figure 1. Excessive fluoride exposure can cause the enamel to become mottled.


  1. Weyant RJ, Tracy SL, Anselmo T, et al. Topical fluoride for caries prevention: Executive summary of the updated clinical recommendations and supporting systemic review. J Am Dent Assoc.2013;144:1279–1291.
  2. Autio-Gold JT, Courts F. Assessing the effect of fluoride varnish on early enamel carious lesions in the primary dentition. J Am Dent Assoc. 2001;132:1247–1253.
The Ask the Expert column features answers to your most pressing clinical questions provided by Dimensions of Dental Hygiene’s online panel of key opinion leaders, including: Jacqueline J. Freudenthal, RDH, MHE, on anesthesia; Nancy K. Mann, RDH, MSEd, on cultural competency; Claudia Turcotte, CDA, RDH, MSDH, MSOSH, on ergonomics; Van B. Haywood, DMD, and Erin S. Boyleston, RDH, MS, on esthetic dentistry; Michele Carr, RDH, MA, and Rachel Kearney, RDH, MS, on ethics and risk management; Durinda Mattana, RDH, MS, on fluoride use; Kandis V. Garland, RDH, MS, on infection control; Mary Kaye Scaramucci, RDH, MS, on instrument sharpening; Stacy A. Matsuda, RDH, BS, MS, on instrumentation; Karen Davis, RDH, BSDH, on insurance coding; Cynthia Stegeman, EdD, RDH, RD, LD, CDE, on nutrition; Olga A.C. Ibsen, RDH, MS, on oral pathology; Jessica Y. Lee, DDS, MPH, PhD, on pediatric dentistry; Bryan J. Frantz, DMD, MS, and Timothy J. Hempton, DDS, on periodontal therapy; Ann Eshenaur Spolarich, RDH, PhD, on pharmacology; and Caren M. Barnes, RDH, MS, on polishing. Log on to to submit your question.

From Dimensions of Dental Hygiene. July 2017;15(7):60.

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