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The Use and Efficacy of Professional Topical Fluorides a Peer-Reviewed Publication Written by N

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The Use and Efficacy of Professional Topical Fluorides a Peer-Reviewed Publication Written by N Earn 2 CE credits This course was written for dentists, dental hygienists, and assistants. The Use and Efficacy of Professional Topical Fluorides A Peer-Reviewed Publication Written by N. Sue Seale, DDS, MSD and Diane M. Daubert, RDH, MS PennWell designates this activity for 2 Continuing Educational Credits Publication date: 9/2010 Go Green, Go Online to take your course Expiry date: 8/31/2013 This course has been made possible through an unrestricted educational grant. The cost of this CE course is $49.00 for 2 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. Educational Objectives used to treat dentinal hypersensitivity, including fluoride varnish The overall goal of this article is to provide the reader with infor- and other in-office desensitizers as well as home-use products. mation on the use, efficacy and safety of professional topical fluo- rides. In addition, current recommendations based on caries risk Recognition of the role of fluoridated water in caries level are addressed. Upon completion of this course, the reader reduction led to the development of other modes will be able to do the following: of fluoride delivery. 1. List the types of professional topical fluorides that are avail- able in the US and Canada 2. List and describe the ADA recommendations on the use of Professional Topical Fluorides professional topical fluorides Professional topical fluorides include fluoride gels, foams, rinses 3. List and describe the evidence on efficacy and safety for and varnishes. Traditionally, professional fluoride treatment in the sodium fluoride varnishes US and Canada involved the use of fluoride gels in trays. This was 4. List and describe the methods by which different professional followed by the introduction of fluoride foams used in trays, which topical fluorides can be applied are generally considered easier to use than gels and have less risk of ingestion of fluoride. Less total fluoride is applied with foam, and Abstract a lower volume of product is used. These factors reduce the risk of Following the discovery that fluoride plays a role in the preven- the patient gagging and swallowing fluoride and also the amount tion of dental caries, professional topical fluorides were devel- of fluoride that could be ingested as a result. Fluoride varnish has oped. Traditionally, fluoride gels and, later, fluoride foams were been in use in Europe for more than 30 years as a method of profes- used in the US and Canada. More recently, fluoride varnishes sional application of topical fluoride.4 In North America, sodium were introduced first in Canada, and then in the US where they fluoride varnish was introduced first in Canada, and later in the US are cleared for use as desensitizing agents. The use of fluoride when it was cleared by the Food and Drug Administration (FDA) varnishes for caries prevention is ‘off-label’ in the US. A recent for use as a desensitizing agent and cavity liner. As such, its use for publication by the ADA Council on Scientific Affairs recom- caries prevention in the US is “off-label” (i.e., it is being used for mends the use of fluoride varnish or fluoride gel for professional a purpose that has not received FDA approval or clearance). Since topical fluoride treatments, with the choice depending on patient its introduction in the United States in the 1990s, its use for the age and risk category. Due to insufficient evidence, foams are prevention of caries has increased among the dental community.5 not recommended for professional topical fluoride treatment and there is no evidence to support rinses. Fluoride gel and varnish The use of fluoride varnish for caries have both proven to be effective, with only varnish recommend- prevention is off-label. ed in the under-6 age group. Evidence-based treatment requires that the clinician assess a patient’s risk level prior to treatment, which can be done with formal risk assessment tools such as Mechanisms of Action CAries Management by Risk Assessment (CAMBRA) and the Professional topical fluorides inhibit demineralization and Caries Assessment Tool (CAT). promote remineralization. Available fluoride helps to prevent the loss of minerals during acid attacks and helps to replenish Introduction demineralized areas. Fluoride varnish utilizes a natural tree Fluoride has maintained an important role in the field of preventive resin base that facilitates adherence of the varnish to the teeth dentistry since the 1940s. The discovery of high levels of fluoride and prolongs the contact time between fluoride and the tooth in the water in the 1930s1 led to the formation of the Dental Hy- surfaces. The fluoride varnish forms calcium fluoride compound giene Unit at the National Institutes headed by H. Trendly Dean, deposits that create a reservoir of fluoride ions that are slowly who noticed an inverse relationship between caries prevalence and released when the pH of plaque drops (Figure 1). This reservoir fluoride concentration that leveled off above 1 ppm. A large-scale acts as a prolonged source of fluoride ions.6,7,8 Numerous studies prospective study that evaluated 30,000 children over a period of 15 have concluded that fluoride varnishes are capable of depositing years resulted in the conclusion that fluoridated water resulted in a large amounts of fluoride on human enamel and it has also been significant reduction in caries for the fluoridated cities.2 The Centers concluded that the amount deposited on demineralized enamel is for Disease Control and Prevention (CDC) reported in 2006 that greater than that on sound enamel.9 69.2 % of US citizens served by public water supplies were receiving As desensitizing agents, fluorides work by blocking the den- fluoridated water.3 Recognition of the role of fluoridated water in tinal tubules. Brannström’s hydrodynamic theory suggests that caries reduction led to the development of other modes of fluoride hypersensitivity is caused by the movement of fluid backward and delivery, including the addition of fluoride to toothpastes, mouth forward within the dentinal tubules in response to stimuli and that rinses, gels and tablets. It also led to the development of methods it is this movement that results in the sensation of pain.10 Therefore, of professional fluoride application for caries prevention, including blocking the dentinal tubules blocks the movement of fluid for a gels, foams, rinses and varnishes. Specific fluoride products are also period of time. 2 www.ineedce.com Figure 1. Release and availability of ions during acid attack Ca++ The patient’s caries risk, age and the scientific as well as /// PO4 F/ evidence-based merits of a product must be considered when recommending fluoride treatment. Ca++ /// PO4 F/ In order to provide evidence-based patient care, it is neces- Acid sary to know the patient’s caries risk. A person is considered to F/ be at low risk if she or he has had no caries, including incipient ++ /// lesions, in the past three years and has no other risk factors. Ca PO4 Caries risk factors include but are not limited to the following: F/ one or two incipient or cavitated carious lesions in the past three Ca++ PO /// 4 years, low socioeconomic status, suboptimal fluoride exposure, xerostomia, poor oral hygiene, cariogenic diet, exposed root sur- faces, drug or alcohol abuse, many existing multisurface restora- Recommendations for Professional Topical Fluorides tions, defective restorations, orthodontic therapy, and physical Treatment recommendations should be based on scientific evidence or mental disability. in combination with knowledge of the patient’s health history, oral condition and preferences. This means that the dental professional Table 2. Caries risk factors needs to understand the scientific and evidence-based merits of Poor oral hygiene a product and also consider the patient’s caries risk when recom- mending fluoride treatment.11 In May 2006, the American Dental Cariogenic diet Association’s Council on Scientific Affairs published recommenda- Incipient or cavitated carious lesions in the past three years tions on the use of available professional topical fluorides by caries Xerostomia risk category, based on results from published clinical trials and Suboptimal fluoride exposure evidence-based studies. The use of only fluoride varnish is recom- Existence of many multisurface restorations mended for patients less than 6 years of age. (Note that recommen- dations for varnish refer to 5% sodium fluoride varnish.) For patients Exposed root surfaces 6 years and older, fluoride varnish or gel is recommended. The rec- Drug or alcohol abuse ommended frequency of use is two to four times per year for patients Low socioeconomic status with a high caries risk, and twice per year for moderate risk patients. Physical or mental disability It is also stated that if a patient has low risk for caries, the person may not receive additional benefit from professional topical fluoride -ap plication. The use of foam is not recommended, due to the fact that Formal caries risk assessment tools that can be used to deter- although laboratory data supports its effectiveness there have been mine a patient’s caries risk include CAries Management By only two clinical trials on its anti-caries efficacy. In addition, the use Risk Assessment (CAMBRA) and the Caries Assessment Tool of 1-minute products (gels and foams) is not endorsed.12 (CAT).13,14 Twenty-five data points are gathered and assessed using CAMBRA, after which a protocol is developed for Table 1. ADA Council on Scientific Affairs recommendations risk management and treatment of the child or adult patient. High Risk Moderate Risk CAT is a separate program recommended by the American Under age 6 Fluoride varnish; 2-4 Fluoride varnish at 6 Academy of Pediatric Dentistry that is intended for use with times per year (6 month month intervals children of all ages.
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