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Reducing Root Caries Risk

Most of the patients I see are elderly and at elevated risk for root caries. What qualities should I look for in a fluoride varnish that will provide the best results in this population?

Most of the patients I see are elderly and at elevated risk for root caries. What qualities should I look for in a fluoride varnish that will provide the best results in this population?

Fluoride is widely accepted as a safe and effective caries preventive agent for all ages. Fluoride is delivered systemically or topically in a variety of forms. Lower concentration topical fluorides are administered at home through the use of rinses, gels, and dentifrice while more concentrated forms—including gels, foams, and varnishes—are reserved for professional use. Selecting the most appropriate fluoride is based on patients’ oral health needs, how well they tolerate the fluoride, their ability to manage the treatment, and other sources of fluoride exposure such as foods and community water.  

As patients age, they experience gingival recession, increasing their risk for root caries. In 2013, the American Dental Association recommended 5% sodium fluoride (NaF) or 2.26% fluoride content varnish application at least twice per year for root caries prevention.1 This recommendation was guided by expert opinion, as well as patient needs and preferences.1 Aside from the recommended percent ion (5%), fluoride varnish qualities are based on patient and provider preferences. Patients prefer a varnish with a pleasant taste and favorable texture, one that is tooth colored after it dries, and a product with the briefest interval before eating and drinking can be resumed post-application. Providers prefer fluoride varnish that flows readily on application and is available in single-dose packaging.   

Recently, more attention has been paid to the efficacy of fluoride in arresting active caries. Fluoride combined with aqueous silver has demonstrated efficacy in treating dental caries for some time. This combination resulted in the formation of silver diamine fluoride (SDF). Current evidence supports the use of SDF over fluoride varnish in the treatment of root caries. An umbrella review and several systematic reviews reported that SDF arrested active root caries and provided superior prevention of new lesions over the use of fluoride varnish.2–6 Further, this off-label use of SDF is reported to be painless, noninvasive, and inexpensive.7 Staining of active carious lesions is a negative side effect of SDF treatment. Two studies, however, examined concerns regarding staining and found that complaints were rare in older adults.8,9 Using this information and your best judgment as a clinician, in addition to considering patient needs and desires, both SDF and fluoride varnish are effective options for treating root caries in the elderly patient population. 


  1. Weyant RJ, Tracy SL, Anselmo T, et al. Topical fluoride for caries prevention: executive summary of the updated clinical recommendations and supporting systematic reviewJ J Am Dent Assoc. 2013;144:1279–1291.
  2. Seifo N., Cassie H., Radford JR., Innes NPT. Silver diamine fluoride for managing carious lesions: an umbrella review. BMC Oral Health. 2019;12:19:145.  
  3. Horst JA., Ellenikiotis H, Milgrom PL. UCSF protocol for caries arrest using silver diamine fluoride: rationale, indications and consent. J Calif Dent Assoc. 2016;44:16–28.  
  4. Oliveira BH, Cunha-Cruz J, Rajendra A, Niederman R. Controlling caries in exposed root surfaces with silver diamine fluoride: a systematic review with meta-analysis. J Am Dent Assoc. 2018;149:671–679.
  5. Urquhart O, Tampi MP, Pilcher L, et al. Nonrestorative treatments for caries: systematic review and network meta-analysis. J Dent Res. 2019;98:14–26. 
  6. Zhang J, Sardana D, Li KY, Leung KCM, Lo ECM. Topical fluoride to prevent root caries: systematic review with network meta-analysis. J Dent Res. 2020;99:506–513.
  7. Chhokar SK, Laughter L. Rowe DJ. Perceptions of registered dental hygienists in alternative practice regarding silver diamine fluoride. J Dent Hyg. 2017;91:53–60. 
  8. Li R, Lo ECM, Liu BY, Wong MCM, Chu CH. Randomized clinical trial on preventing root caries among community-dwelling elders. JDR Clin Trans Res. 2017;2:66–72. 
  9. Tan HP, Lo EC, Dyson JE. Luo Y, Corbet EF. A randomized trial on root caries prevention in elders. J Dent Res. 2010;89:1086–1090.
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, on ethics and risk management; Erin Relich, RDH, BSDH, MSA, 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; 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. May 2022;20(5):46.

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