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 fluorides. 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 available 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 surfaces, 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 recommending 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 recommendations 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. Other formal risk assessment tools are or 3 month intervals) also available, and the criteria and definition of low, medium and high risk vary with the program used. The ADA provid- 6 - 18 years Fluoride varnish or gel; 2 - Fluoride varnish or gel ed definitions of low, medium and high-risk patients by age, of age 4 times per year (6 month at 6 month intervals together with the recommendations for professional topical or 3 month intervals) fluorides in the Council on Scientific Affairs publication.15 Over 18 years Fluoride varnish or gel; Fluoride varnish or gel of age 2 - 4 times per year at 6 month intervals Level of Evidence and Efficacy (6 month or 3 month The studies on professional topical fluorides for caries preven- intervals) tion have largely been conducted on medium- and high-risk Low risk patients may not benefit from professional topical fluorides children and adolescents. One meta-analysis found overall car- Source: Adapted from the ADA Report of the Council on Scientific ies reductions of 38% (DMFS/dmfs) with the use of fluoride Affairs, May 2006. varnishes.16 Many systematic reviews and meta-analyses have www.ineedce.com 3 documented the effectiveness of fluoride varnish, as well as some Children Ages 6-18 Years for fluoride gel, in inhibiting caries in this age group.17 However, In children ages 6-18 years with moderate and high caries risk, professional topical fluorides are also used in adults and geriatric there is evidence from systematic reviews to support the use of patients who have additional needs. Fluoride varnish must be fluoride varnish or gel every six months as well as to support the use reapplied to maintain its caries-preventive effect, as must other of fluoride varnish every three months in high-risk children. The topical fluorides.18,19 As discussed, recommended schedules of level of evidence for the use of fluoride gel every three months in reapplication include two to four times a year, depending on the high-risk children ages 6-18 is lower. For children 6-18 years of age, caries risk of the individual. An intensive treatment protocol a systematic review by the Cochrane Collaboration found a caries using three applications of Duraphat in one week per year over reductions of 28% for gels, and a separate review for varnish found three and four years showed caries reductions of 46% to 67% in DMFS reductions of 46% for permanent teeth and dmfs reductions proximal surfaces.20,21 This intensive regimen would be appro- of 33% for primary teeth in children up to 16 years of age. 25,26 priate for highly mobile individuals who might not be available on a regular two to four times a year schedule, such as migrant families who move frequently. The level of evidence-based docu- There is strong evidence to support the use of mentation of the efficacy of professional topical fluorides differs fluoride varnish or gel every six months in at-risk among age groups and by use. children ages 6-18 years, as well as strong evidence to support the use of fluoride varnish every three Recommended schedules of professional topical months in those at high risk. fluoride reapplication include two to four times a year, depending on caries risk. Orthodontic treatment usually begins during this age range, and it is well established that orthodontic appliances can increase the Children Under 6 Years of Age risk for enamel demineralization around brackets. Investigations In children younger than 6 years, there is strong evidence from have shown that fluoride varnish can reduce or minimize demin- systematic reviews of randomized controlled trials supporting eralization of enamel adjacent to brackets.27,28,29 fluoride varnish applications at six-month intervals for moderate- and high-risk patients and for applications of fluoride Figure 2. At-risk adolescent undergoing orthodontic treatment varnish every three months in high-risk patients. Prior to the introduction of fluoride varnish, there was no safe way to administer topical fluoride to children 0-3 years of age. Their limited ability to control swallowing and variable ability to spit effec- tively on command preclude the use of foams, gels and rinses. These are not recommended for this age group. Fluoride varnish’s tenacious adherence to the tooth provides for slow release of the fluoride over time and results in only a small amount being swallowed at a time. Weintraub et al. reported that children ages 6-44 months who received no varnish were more than two times as likely to develop decay as those who received annual varnish application.22 Stearns et al. reported that children 6-44 months of age who had four or more visits where varnish was applied as a part of a preventive/referral service showed a 39% reduction in caries-related treatment in anterior teeth.23 Fluoride varnish should be part of all preventive strategies aimed Adults (All Patients Over 18 Years of Age) at high-risk children in this age group. The primary uses for fluoride varnish in adults are for reminer- Miller and Vann expanded on the ADA panel’s recommenda- alization or control of root caries in older patients, prevention of tions, which addressed recommendations for topical fluoride use caries in high-risk adults and treatment of dentinal sensitivity. in children under age 6, but not specifically ages 0-3 years; they There is some evidence supporting the use of fluoride of either recommended that “based on available evidence including dose modality (varnish or gel) every six months for patients over 18 reductions and efficacy justifications, we advocate that varnish years of age at moderate and high risk, and for high-risk patients should be the only topical fluoride modality used for children at three-month intervals. The level of evidence is lower and is 0-3. Because of safety concerns we advocate further that varnish based on expert committee reports or opinions rather than pro- should also be the only modality used for children with special spective, randomized clinical trials. health care needs who exhibit attention span and/or cooperation Data on the effectiveness of fluoride varnish being superior problems.”24 to other treatment options for root caries is equivocal. Several

4 www.ineedce.com investigations show equivalence – no superiority of fluoride var- there were no safe ways to administer topical fluoride to children nish over the use of chlorhexidine varnish or stannous fluoride 0-3 years of age until the introduction of fluoride varnish, and solution (8%) or in combination with Cariosolve chemome- certainly the varnish provides a safer delivery system for the chanical technique.30,31 There is tentative support for three- 3-to-6-year age group, where swallowing of gels and foams is monthly application of fluoride varnish for remineralization of a major concern. The risk of dental fluorosis with professional root caries.32 There are no clinical trials providing evidence to topical fluorides is minimal, since children are not frequently support the use of professional topical fluoride gels or foams for exposed to these, as they are to fluoride supplements and other the prevention and treatment of root caries. Support is definitely sources of fluoride.39 There is a warning on package inserts to adequate to recommend using fluoride varnish as a part of a total avoid sodium fluoride varnish in patients who have histories of preventive plan including the other agents investigated in these asthma, as a result of a low but potential risk of allergic reactions reported studies. to the resin base, including contact allergic dermatitis. Isaks- One study found 5% sodium fluoride varnish to produce son reported on two cases of contact allergy to sodium fluoride sensitivity relief results that are equivalent to that of oxalate varnish.40 Miller and Vann reported no adverse outcomes with preparations. In another study 2% fluoride iontophoresis, asthma at the time of their US publication.41 If a patient is al- Gluma Comfort Bond Plus Desensitizer, copal varnish and 5% lergic to the resin contained in the varnish base, or any other sodium fluoride varnish all resulted in significant relief at 24 ingredient, fluoride varnish should not be used for that patient. hours; after 7 days, results were statistically significant for 2% Fluoride varnish is contraindicated if a patient has ulcerative fluoride iontophoresis and Gluma Comfort Bond Plus Desensi- gingivitis or stomatitis. tizer.33,34 A recent study compared the use of 5% sodium fluoride varnish and shellac-based fluoride varnish for sensitivity relief Fluoride vehicles and dosing and found both to be equally effective and to provide relief.35 The first and most extensively studied 5% sodium fluoride var- Fluoride varnish can be effective for up to three to six months for nish was Duraphat. Originally, varnishes were yellow-tinted sensitivity relief, depending on the patient, when used according and dispensed from a tube (Duraphat; Duraflor). A number of to the directions for use.36 5% sodium fluoride varnishes are now available, and they differ in properties such as viscosity, color (clear/white/tinted) and Table 3. Level of evidence for professional topical fluorides - taste. One milliliter of the varnish contains 22.6 mg fluoride/ moderate and high caries risk ml. Some manufacturers provide unit-dosed packaging, which Varnish Gel offers several advantages: each patient gets a controlled amount Under age 6 of fluoride, preventing over-application and minimizing any Moderate risk High for every 6 months Not recommended potential possibility (already minimal) of fluoride ingestion. An High risk High for every 6 months Not recommended additional advantage of unit doses relates to sodium fluoride’s tendency to settle in the varnish due to its particulate nature, and every 3 months Not recommended potentially affecting the amount of fluoride dispensed from 6-18 year-olds multiple use containers. With unit dosing, the amount of sodium Moderate risk High for every 6 months High for every 6 months fluoride will be consistent in each application.42 Fluoride gels are High risk High for every 6 months High for every 6 months dispensed directly into mouth trays from larger bottles, as well and every 3 months Lower for every 3 months as being available in trays with pre-loaded and pre-dosed gel. Over 18 years Lower Lower Most manufacturers have mechanisms to help advise the proper Source: ADA Report of the Council on Scientific Affairs, May 2006. amount of their product to dispense. For a 5% NaF varnish, in general it is advised to provide 5.65 mg F, or 0.25 ml, for the primary dentition; 9.04 mg F, or 0.40 ml, varnish for the mixed Safety dentition; and 11.3 mg F, or 0.50 ml, varnish for the permanent Several aspects provide for the safety of sodium fluoride varnish dentition. For gels, the amount placed in the tray depends on the compared to other methods of delivery of professional topical age of the patient (and thus also the size of the tray) and ranges fluorides. Even though the concentration of fluoride in 5% NaF from 49.2 - 98.4 mg fluoride. varnish (22.6 mg F/ml) is about twice as high as in APF gel (12.3 mg F/ml), the amount required for a treatment ranges from 0.1 Table 4. Treatment doses – 0.5 ml (2.26 - 11.3 mg F) for varnish depending on age, com- Varnish Gel pared with 4-8 ml (49.2-98.4 mg F) with APF gels.37 Additionally, the potential for ingestion is basically solved Permanent dentition 0.5 ml (11.3 mg F) 4 – 8 ml (49.2 – 98.4 mg F) by the tenacious adherence of fluoride varnish to the teeth. Mixed dentition 0.4 ml (9.04 mg F) 4 – 8 ml (49.2 – 98.4 mg F) Thus, any fluoride that is swallowed is minimal and ingested Primary dentition 0.25 ml (5.65 mg F) Not recommended over longer periods of time, virtually eliminating the possibility of nausea, vomiting or other fluoride toxic reactions.38 In fact, Infants 0.1 ml (2.26 mg F) Not recommended www.ineedce.com 5 The following section shows the application in a pediatric and an The directions that patients in all age groups should follow adult case. post-application are specific. The patient should not eat hard and crunchy, or hot, foods for several hours after application Case 1. Application of fluoride varnish for a (typically four to six hours), should refrain from drinking hot pediatric patient liquids or liquids containing alcohol, should avoid alcohol- The child represented in Figure 3 is a three-year old with high containing mouth rinses, and should wait until the following caries risk and early childhood caries. The first step in preparing to day before resuming tooth brushing and flossing. In contrast, it provide a fluoride varnish treatment for a pediatric patient is to de- is generally recommended that patients completely refrain from termine the proper dosage for the child’s dentition, primary, mixed eating or drinking immediately following the application of gels or full permanent. The varnish should be thoroughly mixed after it or foams for at least 30-60 minutes, which, although a shorter is dispensed. When only a thin layer of plaque is present, fluoride period of time, relies on no food or drink being taken (or rinsing) varnish can be directly applied without prior removal of the plaque. and patient compliance. Following topical fluoride application, If a thick layer of plaque is present, this can be removed (prior to if fluoride supplements are used, these should not be taken and the application of professional topical fluoride) by toothbrushing or should be resumed several days later. prophylaxis (neither is considered superior to the other).43 Moisture should be removed from the teeth with gauze or cotton Case 2. Application for an adult periodontal rolls. It is not necessary for the teeth to be air-dried, nor is absolute patient moisture control necessary although excessive saliva flow over the This example involves a 68-year-old adult female with a teeth should be avoided. The varnish is then applied with a brush or history of periodontal surgery and regular three-monthly cotton-tip applicator or the applicator supplied by the manufacturer, periodontal maintenance. The patient is at caries risk due to and until set will flow on the teeth, including into interproximal ar- drug-induced xerostomia, has exposed roots and also com- eas. Fluoride varnish can be rapidly applied and there is no waiting plains of dentinal hypersensitivity. In a periodontal practice time after application. Total application time varies, depending on with patients who commonly have both dentin exposure and how many teeth need to be varnished. It will set in the presence of caries risk factors, it is advantageous to use one treatment intraoral moisture, and no rinsing or suctioning is required follow- that addresses two areas of concern. Part of her periodontal ing the application. The child may be able to feel the thin film of the maintenance therapy includes fluoride varnish application, varnish with his/her tongue. (Note: Tinted varnishes leave a yellow with the dual benefit that it is effective in both preventing car- film over the teeth, and parents and older patients would need to be ies and treating dentinal hypersensitivity. The application of warned of this effect if a tinted varnish is used.) fluoride varnish can be targeted to specific areas. In the case of periodontal patients with extensive areas of exposed roots, the Figure 3a. Missing tooth structure and carious lesion varnish can easily be applied to areas that may not easily be accessed using a gel and tray. It would also be anticipated that the patient would achieve simultaneous relief from dentinal hypersensitivity. The general application technique and post- application instructions are described above.

Figure 4a. Periodontal patient at-risk for caries and with dentinal hypersensitivity

Figure 3b. Application of varnish

6 www.ineedce.com Figure 4b. Application of varnish health dentistry. J Public Health Dent. 1998;58:266-69. 5 Autio-Gold J. Fluoride varnishes for everyday practice. Pract Proced Aesthet Dent. 2005;17:398, 400. 6 Fejerskov O, Thylstrup A, Larsen MJ. Rational use of fluorides in caries prevention: a concept based on possible cariostatic mechanisms. Acta Odontol Scand. 1981;39:241- 49. 7 Ogaard B, Seppa L, Rolla G. Professional topical fluoride applications – clinical efficacy and mechanism of action. Adv Dent Res. 1994;8:190-201. 8 Ten Cate JM. Review on fluoride, with special emphasis on calcium fluoride mechanisms in caries prevention. Eur J Oral Sci. 1997;105(5 pt 2):461-65. 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;131:589-96. 10 Brannstrom M, Astrom A. The hydrodynamics of the dentine: its possible relationship to dentinal pain. Int Dent J. 1972;22:219-27. 11 ADA. Report of the Council on Scientific Affairs. Figure 4c. Application of varnish Professionally applied topical fluoride: evidence-based clinical recommendations. JADA. May 2006;137(8):1151-59. 12 ADA. Report of the Council on Scientific Affairs. Professionally applied topical fluoride: evidence-based clinical recommendations. JADA. May 2006;137(8):1151-59. 13 Young DA, Featherstone JDB, Roth JR, et al. Caries Management by Risk Assessment: Implementation Guidelines. Consensus Statement. Calif Dent J. 2007:799- 805. 14 American Academy of Pediatric Dentists. Policy on the use of a caries-risk assessment tool (CAT) for infants, children and adolescents. Reference Manual 2002-2003. 15-17. Available at: http://www.aapd.org/members/referencemanual/ pdfs/02-03/Caries%20Risk%20Assess.pdf. 15 ADA. Report of the Council on Scientific Affairs. Professionally applied topical fluoride: evidence-based clinical recommendations. JADA. May 2006;137(8):1151-59. 16 Helfenstein U, Steiner M. Fluoride varnishes (Duraphat): a meta-analysis. Community Dent Oral Epidemiol. Note the exposed roots and bifurcations that are accessible with the applicator. 1994;22:1-5. 17 Marinho VC, Higgins JP, Logan S, Sheiham A. Fluoride varnishes for preventing dental caries in children and Summary adolescents (a review). Cochran Database Syst Rev. Professional topical fluoride treatments are recommended for use 2002;3:CD 002279. in patients at risk for dental caries. Based on the evidence and safety 18 Seppa L. Fluoride content of enamel during treatment and considerations, only fluoride varnish is recommended for patients 2 years after discontinuation of treatment with fluoride varnishes. Caries Res. 1984;18:278-81. under the age of 6, while for patients age 6 and older, either fluoride 19 Seppa L, Tuutti H, Luoma H. Post-treatment effect of gel or varnish is recommended. The selection of a professional topi- fluoride varnishes in children with a high prevalence of cal fluoride should be guided by the scientific evidence, age and risk dental caries in a community with fluoridated water. J Dent level of the patient as well as specific intra-oral considerations. Res. 1984;63:1221-22. 20 Petersson LG, Arthursson L, Östberg C, Jonssön G, Gleerup References A. Caries-inhibiting effects of different modes of Duraphat varnish reapplications: a 3-year radiographic study. Caries 1 CDC. Achievements in public health, 1900-1999: fluoridation Res. 1991;24:70-73. water to prevent dental caries. MMWR. October of drinking 21 Skold L, Sundquist B, Eriksson B, Edeland C. Four-year 22, 1999;48(41):933-40. study of caries inhibition of intensive Duraphat application in 2 CDC. Achievements in public health, 1900-1999: 11-15-year-old children. Community Dent Oral Epidemiol. fluoridation of drinking water to prevent dental caries. 1994;22:8-12. MMWR. October 22, 1999;48(41):933-40. 22 Weintraub JA, Ramos-Gomez F, Jue B, Shain S, Hoover 3 CDC. Populations receiving optimally fluoridated public C, Featherstone J, Gansky S. Fluoride varnish efficacy in drinking water – United States, 1992-2006. MMWR. July preventing early childhood caries. J Dent Res. 2006;85:172- 11, 2008;57(27):737-41. 76. 4 Bawden JW. Fluoride varnish: a useful new tool for public 23 Stearns SC, Rozier RG, Pahel BT, Park JY, Quinonez RB. www.ineedce.com 7 Effects of expanding preventive dental care in medical offices Pediatri Dent. 2008;32(4):259-64. for young children covered by Medicaid. http://apha. 42 Vaikuntam J. Fluoride varnishes: should we be using them? confex.com/apha/135am/techprogram/paper_160757. Pediatr Dent. 2000;22(6):513-16. htm. Accessed June 2010. 43 Seppa L. Effect of dental plaque on fluoride uptake by 24 Miller EK, Vann WF. The use of fluoride varnish in children: enamel from a sodium fluoride varnish in vivo. Caries Res. a critical review with treatment recommendations. J Clin 1983;17:71-75. Pediatri Dent. 2008;32(4):259-64. 25 Marinho VC, Higgins JP, Logan S, Sheiham A. A systematic Author Profiles review of controlled trials on the effectiveness of fluoride gels N. Sue Seale, DDS, MSD for the prevention of dental caries in children. J Dent Edu. Dr. N. Sue Seale is Regents Professor, Department of Pediatric 2003;67:448-58. 26 Marinho VC, Higgins JP, Logan S, Sheiham A. Dentistry, Baylor College of Dentistry, Texas A&M Health Sci- Fluoride varnishes for preventing dental caries in ence Center in Dallas, Texas. She received her DDS in 1970, her children and adolescents. Cochrane Database Syst Rev. certificate in pediatric dentistry in 1972 and her MSD in 1979 2002;(3):CD002279. from Baylor and has been a full-time faculty member since 1974. 27 Farhadian N, Miresmaeili A, Eslami B, Mehrabi S. Effect of She was president of the Texas Academy of Pediatric Dentistry fluoride varnish on enamel demineralization around brackets: an in-vivo study. Am J Orthod Dentofacial Orthop. 2008 1996-1997 and received the Distinguished Alumni Award from Apr;133(4 Suppl):S95-98. the Baylor College of Dentistry Alumni Association in 1997; 28 Vivaldi-Rodrigues G, Demito CF, Bowman SJ, Ramos AL. she served on the Board of Trustees of the American Academy The effectiveness of a fluoride varnish in preventing the of Pediatric Dentistry from 1999-2002. In 2001, the American development of white spot lesions. World J Orthod. 2006 Academy of Pediatric Dentistry named her Pediatric Dentist of Summer;7(2):138-44. 29 Gontijo L, de Almeida Cruz R, Brandao PR. Dental enamel the Year and presented her with the Merle C. Hunter Leadership around fixed orthodontic appliances after fluoride varnish Award in 2003. She is a diplomate of the American Board of Pedi- application. Braz Dent J. 2007;18(1):49-53. atric Dentistry and received Fellowship in the American College 30 Schaeken MJ, Keltjens HM, VanDer Hoeven JS. Effects of of Dentists in 1984 and in the International College of Dentists in fluoride and chlorhexidine on the microflora of dental root 2001. She was Chairman of the Department of Pediatric Dentistry surfaces and progression of root-surface caries. J. Dent Res. 1991 Feb;70(2):150-53. at Baylor from 1986 until 2009. 31 Fure S, Lingstrom P. Evaluation of different fluoride treatments of initial root carious lesions in vivo. Oral Health Diane M. Daubert, RDH, MS Prev Dent. 2009;(7):147-54. Ms. Daubert currently works as an affiliate instructor in the de- 32 Schaeken MJ, Keltjens HM, VanDer Hoeven JS. Effects of partment of periodontics at the University of Washington and is fluoride and chlorhexidine on the microflora of dental root also responsible for the management of a faculty intramural prac- surfaces and progression of root-surface caries. J. Dent Res. 1991 Feb;70(2):150-53. tice in the graduate periodontal clinic where she is also the coordi- 33 Merika K, HeftitArthur F, Preshaw PM. Comparison of two nator for clinical research projects. Diane received the University topical treatments for dentine sensitivity. Eur J Prosthodont of Washington School of Dentistry Distinguished Staff Award in Restor Dent. 2006 Mar;14(1):38-41. 2003. She is a member of the American Dental Hygienist’s As- 34 Olusile AO, Bamise CT, Oginni AO, Dosumu OO. Short- sociation, Washington State Dental Hygienist’s Association, and term clinical evaluation of four desensitizing agents. J Contemp Dent Pract. 2008 Jan 1;9(1):22-29. the American Dental Education Association. Diane received her 35 Hoang-Dao BT, Hoang-Tu H, Tran-Thi NN, Koubi G, Bachelor of Science degree in Dental Hygiene from the University Camps J, et al. Clinical efficiency of a natural resin fluoride of Washington and her Master of Science in 2009. She is currently varnish (Shellac F) in reducing dentin hypersensitivity. J enrolled in the PhD program in Oral Biology at the University of Oral Rehabil. 2009;36(2):124-31. Washington. 36 Landry RG, Voyer R. Treatment of dentin hypersensitivity: a retrospective and comparative study of two therapeutic approaches. J Can Dent Assoc. 1990;56(11):1035-41. Acknowledgment 37 Miller EK, Vann WF. The use of fluoride varnish in children: Figure 2 courtesy of Dr. Michael Florman. Figures 3a and 3b courtesy of a critical review with treatment recommendations. J Clin Dr. Simon Lin. Cover tooth illustration © Andreus | Dreamstime.com Pediatri Dent. 2008;32(4):259-64. 38 Ekstrand J, Koch G, Petersson LG. Plasma fluoride Disclaimer concentration and urinary fluoride excretion in children following application of the fluoride-containing varnish The author(s) of this course has/have no commercial ties with the Duraphat. Caries Res. 1980;14:185-89. sponsors or the providers of the unrestricted educational grant for 39 Beltran-Aguilar ED, Goldstein JW, Lockwood SA. Fluoride this course. varnishes: a review of their clinical use, cariostatic mechanism, efficacy and safety. J Am Dent Assoc. 2000;131:589-96. Reader Feedback 40 Isaksson M, Bruz M, Bjorkner B, Niklasson B. Contact allergy to Duraphat. Scand J Dent R. 1993;101:49-51. We encourage your comments on this or any PennWell course. 41 Miller EK, Vann WF. The use of fluoride varnish in children: For your convenience, an online feedback form is available at www. a critical review with treatment recommendations. J Clin ineedce.com.

8 www.ineedce.com Online Completion Use this page to review the questions and answers. Return to www.ineedce.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your answers. An immediate grade report will be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or printed anytime in the future by returning to the site, sign in and return to your Archives Page.

Questions

1. Recognition of the role of ______in caries 11. ______is a caries risk factor. a. remineralization or control of root caries in older reduction led to the development of other a. Submicrobial fluoride exposure patients modes of fluoride delivery. b. Suboptimal fluoride exposure b. prevention of caries in high-risk adults a. topical fluoride c. Lack of fluoride exposure c. treatment of dentinal sensitivity b. topical iodide d. b and c d. all of the above c. fluoridated water 12. Incipient or cavitated carious lesions are 21. Fluoride varnish can be effective for up to d. all of the above only a risk factor if they have occurred in the ______for sensitivity relief. 2. Sodium fluoride varnish is cleared by the last ______years. a. one to two years Food and Drug Administration (FDA) for a. seven b. three years use as a ______. b. six c. three to six months a. desensitizing agent c. five d. six to twelve months d. none of the above b. desensitizing agent and cavity liner 22. Fluoride gel is recommended for patients c. desensitizing agent and caries preventive 13. One meta-analysis found overall caries d. none of the above ______at risk for caries. reductions of ______with the use of a. under age 6 3. Professional topical fluorides act to fluoride varnishes. b. under age 3 ______. a. 28% c. age 6 and over a. inhibit remineralization and promote demineralization b. 38% d. all of the above b. inhibit demineralization and promote remineralization c. 48% c. promote the status quo with incipient lesions d. none of the above 23. Fluoride varnish is contraindicated if a d. all of the above patient ______. 14. An intensive fluoride varnish regimen would a. has ulcerative gingivitis 4. Fluoride varnish utilizes ______that be appropriate for ______who might not b. has stomatitis facilitates adherence of the varnish to the be available on a regular two to four times a c. is allergic to one of the ingredients teeth and prolongs the contact time between year schedule. d. all of the above fluoride and the tooth surfaces. a. immobile individuals 24. One milliliter of the varnish contains a. an agar gum base b. highly mobile individuals b. a natural tree resin base c. low caries risk patients ______. c. a colloidal base d. all of the above a. 2.26 mg fluoride/ml d. none of the above b. 22.6 mg fluoride/ml 15. Prior to the introduction of ______, there 5. As desensitizing agents, fluorides work by c. 226 mg fluoride/ml was no safe way to administer topical fluoride d. none of the above ______. to children 0-3 years of age. a. blocking nerve transmission a. fluoride gel 25. Infants require ______of fluoride b. ameliorating nerve transmission b. fluoride rinse varnish. c. blocking dentinal tubules c. fluoride varnish a. 0.1 ml d. all of the above d. all of the above b. 0.4 ml 6. The American Dental Association’s Council c. 0.75 ml 16. Stearns et al. reported that children 6-44 d. none of the above on Scientific Affairs published recommenda- months of age who had four or more visits tions on the use of available professional where varnish was applied as a part of a pre- 26. The dose of fluoride varnish for the mixed topical fluorides in ______. ventive/referral service showed a ______dentition is ______. a. March 2004 reduction in caries-related treatment in a. 0.2 ml b. May 2006 anterior teeth. b. 0.4 ml c. July 2008 c. 0.6 ml d. January 2010 a. 19% b. 29% d. 0.8 ml 7. The use of ______is recommended for c. 39% 27. Following application of fluoride varnish, patients less than 6 years of age at moderate d. 49% the patient ______. or high risk for caries. 17. In children ages 6-18 years with moderate a. must avoid earing hard, crunchy or hot foods a. fluoride varnish b. must avoid drinking hot liquids or liquids containing alcohol b. fluoride varnish or gel and high caries risk, there is strong evidence to support the use of ______. c. should resume regular oral hygiene the following day c. fluoride varnish, gel or foam d. all of the above d. none of the above a. fluoride varnish every 6 months b. fluoride gel every six months 28. Following application of fluoride gel, the 8. The use of 1-minute products (gels and c. fluoride varnish every 3 months in high risk children patient ______. foams) is ______. d. all of the above a. should refrain from eating for at least 30-60 minutes a. strongly endorsed b. should refrain from drinking for at least 30-60 minutes b. ineffective 18. Orthodontic appliances can ______the c. should refrain from crunchy foods for a day c. never advised risk for enamel demineralization around d. a and b d. none of the above brackets. a. decrease 29. When only a ______is present, fluoride 9. Fluoride varnish or gel at 6 month intervals is b. maintain recommended for children ______. varnish can be directly applied without prior c. increase removal of the plaque. a. age 6 and older d. none of the above b. under age 6 a. the pellicle c. over age 13 only 19. Data on the effectiveness of fluoride varnish b. a thick layer of plaque d. a and b being superior to other treatment options for c. a thin layer of plaque d. all of the above 10. In order to provide evidence-based patient root caries is ______. care, it is necessary to know the patient’s a. unequivocal 30. The selection of a professional topical b. equivocal fluoride should be guided by ______. ______. c. overwhelming a. caries scale a. scientific evidence d. none of the above b. caries risk b. age and risk level of the patient c. caries future 20. The primary use for fluoride varnish in c. specific intra-oral considerations d. all of the above adults is for______. d. all of the above ANSWER SHEET The Use and Efficacy of Professional Topical Fluorides

Name: Title: Specialty:

Address: E-mail:

City: State: ZIP: Country:

Telephone: Home ( ) Office ( ) Lic. Renewal Date:

Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 2 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 216.398.7822

If not taking online, mail completed answer sheet to Educational Objectives Academy of Dental Therapeutics and Stomatology, 1. List the types of professional topical fluorides that are available in the US and Canada A Division of PennWell Corp. P.O. Box 116, Chesterland, OH 44026 2. List and describe the ADA recommendations on the use of professional topical fluorides or fax to: (440) 845-3447 3. List and describe the evidence on efficacy and safety for sodium fluoride varnishes

4. List and describe the methods by which different professional topical fluorides can be applied For immediate results, go to www.ineedce.com to take tests online. Answer sheets can be faxed with credit card payment to (440) 845-3447, (216) 398-7922, or (216) 255-6619. Course Evaluation Payment of $49.00 is enclosed. Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. (Checks and credit cards are accepted.) If paying by credit card, please complete the 1. Were the individual course objectives met? Objective #1: Yes No Objective #3: Yes No following: MC Visa AmEx Discover Objective #2: Yes No Objective #4: Yes No Acct. Number: ______2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0 Exp. Date: ______Charges on your statement will show up as PennWell 3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0

4. How would you rate the objectives and educational methods? 5 4 3 2 1 0

5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0

6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0

7. Was the overall administration of the course effective? 5 4 3 2 1 0

8. Do you feel that the references were adequate? Yes No

9. Would you participate in a similar program on a different topic? Yes No

10. If any of the continuing education questions were unclear or ambiguous, please list them. ______

11. Was there any subject matter you found confusing? Please describe. ______

12. What additional continuing dental education topics would you like to see? ______AGD Code 258, 430

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.

AUTHOR DISCLAIMER INSTRUCTIONS COURSE CREDITS/COST RECORD KEEPING The author(s) of this course has/have no commercial ties with the sponsors or the providers of All questions should have only one answer. Grading of this examination is done All participants scoring at least 70% on the examination will receive a verification PennWell maintains records of your successful completion of any exam. Please contact our the unrestricted educational grant for this course. manually. Participants will receive confirmation of passing by receipt of a verification form verifying 2 CE credits. The formal continuing education program of this sponsor offices for a copy of your continuing education credits report. This report, which will list form. Verification forms will be mailed within two weeks after taking an examination. is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for all credits earned to date, will be generated and mailed to you within five business days SPONSOR/PROVIDER current term of acceptance. Participants are urged to contact their state dental boards of receipt. This course was made possible through an unrestricted educational grant. No EDUCATIONAL DISCLAIMER for continuing education requirements. PennWell is a California Provider. The California manufacturer or third party has had any input into the development of course content. The opinions of efficacy or perceived value of any products or companies mentioned Provider number is 4527. The cost for courses ranges from $49.00 to $110.00. CANCELLATION/REFUND POLICY All content has been derived from references listed, and or the opinions of clinicians. in this course and expressed herein are those of the author(s) of the course and do not Any participant who is not 100% satisfied with this course can request a full refund by Please direct all questions pertaining to PennWell or the administration of this course to necessarily reflect those of PennWell. Many PennWell self-study courses have been approved by the Dental Assisting National contacting PennWell in writing. Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or [email protected]. Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet Completing a single continuing education course does not provide enough information DANB’s annual continuing education requirements. To find out if this course or any other © 2010 by the Academy of Dental Therapeutics and Stomatology, a division COURSE EVALUATION and PARTICIPANT FEEDBACK to give the participant the feeling that s/he is an expert in the field related to the course PennWell course has been approved by DANB, please contact DANB’s Recertification of PennWell We encourage participant feedback pertaining to all courses. Please be sure to complete the topic. It is a combination of many educational courses and clinical experience that Department at 1-800-FOR-DANB, ext. 445. survey included with the course. Please e-mail all questions to: [email protected]. allows the participant to develop skills and expertise. Customer Service 216.398.7822