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INTRODUCTION

Dental caries remains the most common disease of childhood and often causes a significant decrease in quality of life for those most severely affected. The risk factors for dental caries are well known and each patient requires an individual assessment of caries risk. Topical fluorides are safe and effective allies in the fight to control this disease. The Colgate-Palmolive Company is delighted to have provided an unrestricted educational grant to support the second article of this four-part series in collaboration with the American Academy of Pediatric Dentistry. The article provides a timely review of the topical fluorides on the market today and their guidelines for use with your patients.

—Barbara Shearer, BDS, MDS, PhD, Director of Scientific Affairs, Colgate Oral Pharmaceuticals

FLUORIDE THERAPY IS A SAFE AND EFFECTIVE STRATEGY FOR REDUCING THE RISK OF CARIES AND REVERSING ENAMEL DEMINERALIZATION.¹

Preventon of dental caries in children is a multi-factorial process, however, no strategy is more important or more effective than the age-appropriate use of fluoride.² While fluoride can be delivered both systemically and topically, this article focuses on topical applications, eg, gel, foam, varnish, toothpaste, and mouthrinses.

DOSAGE CONSIDERATIONS

In order to recommend the appropriate type and dosage of fluoride therapy, a child’s daily fluoride exposure must be determined. Fluoridated water is now frequently included in processed foods and beverages, creating a “halo” effect. In addition to drinking water, fluoride can be found in infant formulas and foods, milk, fruit juices, carbonated soft drinks, raisins, tea, and cereal. All sources of dietary fluoride should be considered when determining total exposure.³ The United States Centers for Disease Control and Prevention (CDC) maintains a website that lists the fluoridation status of community water supplies (http://apps.nccd.cdc.gov/MWF/index.asp). Many food, beverage, and infant formula manufacturers, however, do not include fluoride concentration with the nutritional content on food labels, making the exact determination of fluoride exposure difficult.

TOPICAL DELIVERY

The amount of fluoride delivered in topical applications varies according to both concentration and frequency of use. Typically, the higher the concentration, the lower the recommended frequency of application. Fluoride varnishes, for example, have a very high concentration and are usually applied twice a year, whereas toothpastes have a low concentration and are used twice daily. Table 1 provides evidence-based clinical recommendations for professionally-applied topical fluoride as provided by the American Dental Association (ADA).⁴

TOOTHPASTE

Ideally, a child’s toothpaste should carry the ADA Seal of Acceptance, rank low in abrasiveness, and contain the appropriate amount of fluoride. The majority of toothpastes used in the US contain 1,000 ppm to 1,100 ppm of sodium fluoride or sodium monofluorophosphate (MFP); 100 g of toothpaste containing 0.76 g MFP equates to 0.1 g fluoride. High strength, prescription-only fluoride toothpastes, generally contain 1.1% (5,000 ppm) sodium fluoride and are recommended as part of a prevention program in older children at high caries risk.⁴

Most brands of children’s toothpastes are fluoridated and many have popular characters and different flavors to make them more attractive to children. Parents should be instructed to supervise brushing and dispense toothpaste for children under 7 to ensure the correct amount of toothpaste is used. Excessive use or consumption of the toothpaste should be avoided.

The American Academy of Pediatric Dentistry (AAPD) recommends that children aged 2 and older use a small, pea-size amount of fluoride toothpaste (Figure 1). This amount provides an effective dose of fluoride and reduces the risk of excessive ingestion. ⁵ Parents and caregivers should also teach their child to expectorate the toothpaste at a young age. A smear of fluoride toothpaste can be used in children younger than 2 (Figure 1).⁵ An alternative for younger children is to use nonfluoridated toothpaste until they are able to expectorate. For children at high risk of caries, early implementation of fluoride toothpaste should be part of their caries-prevention regimen.

A general rule for toothbrushing in children is the “2-2-2” method. Twice a day, every morning following breakfast and every night prior to bed, the teeth should be brushed with a soft-nylon bristle manual or electric toothbrush for a minimum of 2 minutes (less time is required if the full primary dentition has yet to erupt), with nothing entering the mouth for 2 hours following each session. Toothbrushing should begin as soon as the first teeth erupt. For most children the primary caregiver should be responsible for brushing the child’s teeth until 7 or 8, when most children gain the manual dexterity and patience necessary to perform the brushing completely by themselves. A good developmental marker for independent brushing is the child’s ability to tie his or her own shoes. After brushing, the child should expectorate, but not rinse with water. This will maximize the amount of time the fluoride ions have to interact with the enamel surface and thus enhance the anticaries effect.⁶

MOUTHRINSES

Fluoride-containing mouthrinses can provide additional benefits to an anticaries regimen. They help increase the fluoride concentration on the enamel surface and may also reduce the amount of dental biofilm in children at high risk of caries. The most frequent fluoride compound used in mouthrinses is sodium fluoride. Over-the-counter solutions recommended for daily use typically contain 0.05% sodium fluoride (225 ppm fluoride). Prescription mouthrinses contain 0.2% sodium fluoride (900 ppm fluoride) and can be recommended for the prevention of dental caries in high risk children 6 years and older.

Parents and children should be advised that both over-the-counter and prescription mouthrinses should not be swallowed, and that they must be held in the mouth for a full 60 seconds in order to achieve their maximum effect.⁵

FLUORIDE GEL AND FOAM

Fluoride gel is also effective in preventing caries in school-aged children.⁴ Gels and foams are particularly helpful in children who are at high risk of caries, such as orthodontic patients, patients undergoing head and neck radiation, patients with decreased salivary flow, patients without a fluoridated water supply, and children whose permanent molars are not sealed.

Moderate-risk patients should receive fluoride gel or foam applications at 6-month intervals whereas, high-risk patients should receive gel applications at 3-month to 6-month intervals.⁴ The application time for fluoride gel or foam is 4 minutes for all age groups. For most products, a 1-minute application time is not recommended.⁷ Children should be closely monitored during administration of fluoride gel or foam in order to minimize ingestion.¹ Children may have difficulty with the time necessary for proper application and the large volume of gel or foam that is applied. This may increase the risk of fluoride ingestion thus causing nausea and/or vomiting. Also, patient compliance may be poor due to the strong taste associated with most gels and foams. After application, patients should not rinse, eat, or drink for at least 30 minutes.

FLUORIDE VARNISH

In children with moderate to high caries risk, fluoride varnish is a valuable tool.¹⁰ Fluoride varnish has been used for caries prevention in Canada and Europe for more than 30 years, however, the federal Food and Drug Administration has only approved fluoride varnish for reducing dentinal hypersensitivity. Regardless, many practitioners in the US use fluoride varnish for caries prevention.

The purpose of fluoride varnish application is to slow, arrest, and possibly reverse the progression of caries.⁸ Fluoride varnish applied every 6 months is effective in preventing caries in both primary and mixed dentition. 4 For patients at high risk of caries or with existing white spot lesions, a higher frequency of fluoride varnish application may be beneficial. Fluoride varnishes have practical advantages over gels and foams. Ease of application, minimal risk of ingestion, prolonged exposure time, minimal discomfort, inoffensive taste, and small volume of material make fluoride varnish ideal for use in young children. An additional benefit is that, unlike gels and foams, children can drink and eat soft, nonsticky foods immediately after the varnish application, thus, increasing compliance.

The application technique for fluoride varnish begins with a careful examination of all the teeth to identify any areas of demineralized enamel. If the child is very young or uncooperative, the knee-to-knee position with the parent can be used (Figure 2). The teeth should be dried with a gauze one quadrant at a time. The varnish can then be applied with a small brush as a thin coat to all tooth surfaces but primarily focusing on the buccal and lingual smooth surfaces and any demineralized areas or white spot lesions (Figure 3). The varnish sets upon contact with the tooth and saliva with immediate adhesion. Children and parents should be instructed to avoid hot, hard, or crunchy foods and drinks immediately after application and to skip brushing their teeth the night following their visit to maximize contact between the fluoride varnish and the enamel.⁹

RISKS OF EXCESSIVE FLUORIDE EXPOSURE

The use of fluoride-containing products to help prevent dental caries is safe and effective, but there are risks to inappropriate exposure. The most common is mild enamel fluorosis. Enamel fluorosis is generally a cosmetic concern mainly affecting the maxillary central and lateral incisors with white specks or streaks. Development of fluorosis depends on the amount, duration, and timing of excessive fluoride intake.

In order for fluorosis to occur, a child needs to ingest an excessive amount of fluoride during the period of enamel formation of the maxillary incisors, generally from age 1 to 4. This ingestion usually occurs when children consume excessive toothpaste while brushing. Some unsupervised children also ingest toothpaste directly from the tube.¹⁰ Other risk factors, such as inappropriate fluoride supplementation via drops or tablets for example, can also increase the risk of fluorosis. For most children, the risk of mild fluorosis is typically outweighed by the anticaries benefit of fluoride therapy. Nevertheless, parents should be advised of the potential risks of excessive fluoride exposure and encouraged to supervise the dispensing of toothpaste and toothbrushing until age 7.

ORAL HEALTH PROMOTION AND ADVOCACY

Dental hygienists, general dentists, and pediatric dentists should work together to develop caries prevention plans that include the appropriate use of fluoride therapy (Table 2). The dental team should provide anticipatory guidance to parents based on the age of the child, caries risk assessment, and the forms of fluoride therapy available. Dental hygienists are ideally suited to provide oral health education and promotion to parents and children. This guidance should also extend to other caregivers, health care providers, and community-based organizations. Dental hygienists can also serve as strong advocates for evidence-based oral health policy. Whether it is at the local, state, or national level, dental hygienists should have a strong voice in promoting sound policy decisions on all forms of safe and effective fluoride therapy for children.

REFERENCES

1. American Academy on Pediatric Dentistry Liaison with Other Groups Committee; American Academy on Pediatric Dentistry Council on Clinical Affairs. Policy on use offluoride. Pediatr Dent. 2011–2012;33:40–41.
2. Adair SM. Evidence-based use of fluoride in contemporary pediatric dental practice. Pediatr Dent. 2006;28:133–142.
3. Levy SM, Kohout FJ, Kiritsy MC, Heilman JR, Wefel JS. Infants’ fluoride ingestion from water, supplements and dentifrice. J Am Dent Assoc. 1995;126:1625–1632.
4. American Dental Association Council of Scientific Affairs. Professionally applied topical fluoride: evidence-based clinical recommendations. J Am Dent Assoc. 2006;137:1151–1159.
5. American Academy on Pediatric Dentistry Liaison with Other Groups Committee; American Academy on Pediatric Dentistry Council on Clinical Affairs. Guideline on fluoridetherapy. Pediatr Dent. 2011–2012;33:153–156.
6. Spolsky VW, Black BP, Jenson L. Products—old, new, and emerging. J Calif Dent Assoc. 2007;35:724–737.
7. Marinho VC, Higgins JP, Logan S, Sheiiham A. Fluoride gels for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2002:CD002280.
8. Weintraub JA, Ramos-Gomez F, Jue B, et al. Fluoride varnish efficacy in preventing early childhood caries. J Dent Res. 2006;85:172–176.
9. Beltran-Aguilar ED, Goldstein JW, Lockwood SA. Fluoride varnishes. A review of their clinical use, cariostatic mechanism, efficacy and safety. J Am Dent Assoc.2000;131:589–596.
10. Berg J, Gerweck C, Hujoel PP, et al. Evidence-based clinical recommendations regarding fluoride intake from reconstituted infant formula and enamel fluorosis: a reportof the American Dental Association Council on Scientific Affairs. J Am Dent Assoc. 2011;142:79–87.

 

From Dimensions of Dental Hygiene. June 2012; 10(6): 19-22.