Prevention. Part 7: professionally applied topical fluorides for caries prevention

This paper reviews the use of professionally applied topical fluorides (PATF) in caries prevention. PATFs are indicated for children and adults with one or more decayed smooth surfaces and/or those who are at high caries risk. Frequency of administration depends on the patient's caries risk, and is usually every 6 months. The effectiveness of fluoride varnish and gel applications has been well established in caries prevention trials involving permanent teeth. Although both types are effective, varnish may be preferred because it is easier to apply, reduces the risk of fluoride over-ingestion, and has greater patient acceptance. Fluoride foams are similar products to gels, but have not been tested clinically. The use of in-office two-part rinses is not recommended because they have not been proven effective. A cleaning, or prophylaxis, is not necessary before the application of topical fluoride for caries prevention. In conclusion, when used appropriately, PATFs are a safe, effective means of reducing caries risk among high-risk populations.     

Three restorative materials and topical fluoride gel used in xerostomic patients: a clinical comparison

BACKGROUND: The authors compare the incidence of recurrent caries around two glass ionomer restorative materials and one amalgam material. METHODS: The authors placed 111 restorations in nine xerostomic patients. Patients were given oral hygiene instructions and fluoride gel to use daily. The authors evaluated the restorations clinically and with photographs and impressions at six months, one year and two years according to criteria for marginal adaptation, anatomical form, caries in adjacent tooth structure and caries at the cavosurface margin. The authors divided patients into users and nonusers of fluoride. RESULTS: At the two-year recall appointments, the authors evaluated 95 (86 percent) of the 111 restorations. They analyzed two-year data using an analysis of variance for repeated measures and Fisher's post hoc test. The study results showed no significant differences among materials in regard to caries at the cavosurface margin among fluoride users. However, among fluoride nonusers, patients with amalgam restorations had a significantly higher incidence of caries at the cavosurface margins than did patients with either of the two glass ionomer restorations. The authors found no statistically significant difference between restorations with regard to marginal integrity or anatomical form. However, one patient exhibited failure of glass ionomer restorations owing to material loss. CONCLUSIONS: Less caries developed at the margins of glass ionomer restorations compared with amalgam restorations in xerostomic patients who did not routinely use a neutral topical sodium fluoride gel. CLINICAL IMPLICATIONS: Fluoride-releasing materials may reduce caries surrounding restorations in high-risk patients who do not routinely use topical fluoride. Patients who routinely used topical fluoride gel did not develop recurrent caries, and clinicians should encourage the use of fluoride gel on a daily basis.     

Professionally applied topical fluoride: evidence-based clinical recommendations

With the dramatic increase in the amount of scientific information available about oral health, an evidence-based approach to oral health care and the practice of dentistry is necessary. There is a need to summarize, critique, and disseminate scientific evidence and to translate the evidence into a practical format that is used easily by dentists. The evidence-based clinical recommendations in this report were developed by an expert panel established by the American Dental Association Council on Scientific Affairs that evaluated the collective body of scientific evidence on the effectiveness of professionally applied topical fluoride for caries prevention. The recommendations are intended to assist dentists in clinical decision making. MEDLINE and the Cochrane Library were searched for systematic reviews and clinical studies of professionally applied topical fluoride-including gel, foam, and varnish-through October 2005. Panelists were selected on the basis of their expertise in the relevant subject matter. The recommendations are stratified by age groups and caries risk and indicate that periodic fluoride treatments should be considered for both children and adults who are at moderate or high risk of developing caries. Included in the clinical recommendations is a summary table that can be used as a chairside resource. The dentist, knowing the patient's health history and vulnerability to oral disease, is in the best position to make treatment decisions in the interest of each patient. These clinical recommendations must be balanced with the practitioner's professional expertise and the individual patient's preferences.     

Professionally applied topical fluoride: evidence-based clinical recommendations

BackgroundWith the dramatic increase in the amount of scientific information available about oral health, an evidence-based approach to oral health care and the practice of dentistry is necessary. There is a need to summarize, critique and disseminate scientific evidence and to translate the evidence into a practical format that is used easily by dentists The evidence-based clinical recommendations in this report were developed by an expert panel established by the American Dental Association Council on Scientific Affairs that evaluated the collective body of scientific evidence on the effectiveness of professionally applied topical fluoride for caries prevention. The recommendations are intended to assist dentists in clinical decision making.Types of Studies ReviewedMEDLINE and the Cochrane Library were searched for systematic reviews and clinical studies of professionally applied topical fluoride—including gel, foam and varnish—through October 2005.ResultsPanelists were selected on the basis of their expertise in the relevant subject matter. The recommendations are stratified by age groups and caries risk and indicate that periodic fluoride treatments should be considered for both children and adults who are at moderate or high risk of developing caries. Included in the clinical recommendations is a summary table that can be used as a chairside resource.Clinical ImplicationsThe dentist, knowing the patient's health history and vulnerability to oral disease, is in the best position to make treatment decisions in the interest of each patient. These clinical recommendations must be balanced with the practitioner's professional expertise and the individual patient's preferences.     

Comparison of dental prophylaxis and toothbrushing prior to topical APF applications

This study was conducted to evaluate the effect of dental prophylaxis prior to the topical application of acidulated phosphate fluoride solution applied twice a year in schoolchildren. Experimental groups were: Group I--control group, had no treatment. Group II--twice yearly topical application of acidulated phosphate fluoride solution with prior professional prophylaxis with rubber cup and non fluoride paste. Group III--twice yearly topical application of acidulated phosphate fluoride solution with prior toothbrushing with a non-fluoridated prophy paste. After 18 months analysis of 160 children in each study group led to the following conclusions: 1. Acidulated phosphate fluoride topical applications are effective in the prevention of dental caries. 2. The omission of a professional prophylaxis prior to topical fluoride application does not affect significantly the caries preventive effect.     

Prevention and reversal of dental caries: role of low level fluoride

Dental caries is a bacterially based disease that progresses when acid produced by bacterial action on dietary fermentable carbohydrates diffuses into the tooth and dissolves the mineral, that is, demineralization. Pathological factors including acidogenic bacteria (mutans streptococci and lactobacilli), salivary dysfunction, and dietary carbohydrates are related to caries progression. Protective factors which include salivary calcium, phosphate and proteins, salivary flow, and fluoride in saliva can balance, prevent or reverse dental caries. Fluoride works primarily via topical mechanisms which include (1) inhibition of demineralization at the crystal surfaces inside the tooth, (2) enhancement of remineralization at the crystal surfaces (the resulting remineralized layer is very resistant to acid attack), and (3) inhibition of bacterial enzymes. Fluoride in drinking water and in fluoride-containing products reduces tooth decay via these mechanisms. Low but slightly elevated levels of fluoride in saliva and plaque provided from these sources help prevent and reverse caries by inhibiting demineralization and enhancing remineralization. The level of fluoride incorporated into dental mineral by systemic ingestion is insufficient to play a significant role in caries prevention. The effect of systemically ingested fluoride on caries is minimal. Fluoride "supplements" can be best used as a topical delivery system by sucking or chewing tablets or lozenges prior to ingestion.     

Topical fluorides in caries prevention and management: a North American perspective.

A review of evidence-based literature indicates incomplete evidence for the efficacy of most measures currently used for caries prevention, with the exception of fluoride varnishes and the use of fluoride-based interventions for patients with hyposalivation. Not all fluoride agents and treatments are equal. Different fluoride compounds, different vehicles, and vastly different concentrations have been used with different frequencies and durations of application. These variables can influence the clinical outcome with respect to caries prevention and management. The efficacy of topical fluoride in caries prevention depends on a) the concentration of fluoride used, b) the frequency and duration of application, and to a certain extent, c) the specific fluoride compound used. The more concentrated the fluoride and the greater the frequency of application, the greater the caries reduction. Factors besides efficacy, such as practicality, cost, and compliance, influence the clinician's choice of preventive therapy. For noncavitated smooth surface carious lesions in a moderate caries-risk patient, the appropriate fluoride regimen would be semiannual professional topical application of a fluoride varnish containing 5 percent NaF (22,600 ppm of fluoride). In addition, the patient should use twice or thrice daily for at least one minute a fluoridated dentifrice containing NaF, MFP, or SnF2 (1,000-1,500 ppm of fluoride), and once daily for one minute a fluoride mouthrinse containing .05 percent NaF (230 ppm of fluoride). If the noncavitated carious lesion involves a pit or fissure, the application of an occlusal sealant would be the most appropriate preventive therapy. The management of the high caries-risk patient requires the use of several preventive interventions and behavioral modification, besides the use of topical fluorides. For children over six years of age and adults, both office and self-applied topical fluoride treatments are recommended. For office fluoride therapy at the initial visit, a high-concentration agent, either a 1.23 percent F APF gel (12,300 ppm of fluoride) for four minutes in a tray or a 5 percent NaF varnish (22,600 ppm of fluoride), should be applied directly to the teeth four times per year. Self-applied fluoride therapy should consist of the daily five-minute application of 1.1 percent NaF or APF gel (5,000 ppm of fluoride) in a custom-fitted tray. For those who cannot tolerate a tray delivery owing to gagging or nausea, a daily 0.05 percent NaF rinse (230 ppm of fluoride) for 1 minute is a less effective alternative. In addition, the patient should use twice or thrice daily for at least 1 minute a fluoridated dentifrice as described above for treatment of noncavitated carious lesions. In order to avoid unintentional ingestion and the risk of fluorosis in children under six years of age, fluoride rinses and gels should not be used at home. Furthermore, when using a fluoride dentifrice, such children should apply only a pea-size portion on the brush, should be instructed not to eat or swallow the paste, and should expectorate thoroughly after brushing. Toothbrushing should be done under parental supervision. To avoid etching of porcelain crowns and facings, neutral NaF is indicated in preference to APF gels for those patients who have such restorations and are applying the gel daily. The rationale for these recommendations is discussed. Important deficiencies in our knowledge that require further research on topical fluoride therapy in populations with specific needs are identified.     

Evidence-based use of fluoride in contemporary pediatric dental practice

Fluoride is an important and effective means of reducing the caries incidence in children. Multiple fluoride products are available to dentists for use with their patients at risk for dental caries. The purposes of this paper are to: (1) review clinically salient evidence, primarily systematic reviews and meta-analyses, for the effectiveness of fluoride options and, where possible, combinations of fluoride exposures; and (2) make recommendations to dental practitioners based on the available evidence for the use of these various approaches in contemporary practice, particularly regarding the use of multiple fluoride sources. The available data suggest that therapeutic use of fluoride for children should focus on regimens that maximize topical contact, preferably in lower-dose, higher-frequency approaches. Current best practice includes recommending twice-daily use of a fluoridated dentifrice for children in optimally fluoridated and fluoride-deficient communities, coupled with professional application of topical fluoride gel, foam, or varnish. The addition of other fluoride regimens should be based on periodic caries risk assessments, recognizing that the additive effects of multiple fluoride modalities exhibit diminishing returns.     

Prevention of fissure caries in rats by dietary F supplement with and without topical application of F and Sr + F

In our previous studies, combined dietary and topical fluoride have shown to be more effective than each alone. Moreover, supplementation of chlorhexidine-fluoride solution with Sr was beneficial for caries prevention in rats. In the present study, the caries-preventive effect of fluoride added to the diet plus F and/or Sr applications was studied in two experiments with rats. One group received dietary fluoride supplement only. In other groups, either a Sr solution, a fluoride varnish, or a Sr solution plus fluoride varnish were applied to newly erupted molars. In addition, one group received both topical applications of Sr + F and dietary fluoride. Caries development was followed longitudinally during periods of 15, 30 or 54 days. The greatest and most significant reduction of caries resulted from the combination of fluoride varnish plus dietary fluoride supplement. Treatment with Sr solution at the beginning of the experiment had no effect on caries either alone or combined with fluoride varnish. It was found that caries increased rapidly and then levelled off after the 30-days feeding period in all groups. In the treatment groups, however, caries was arrested at a considerably lower level than in the control group.     

A re-examination of the pre-eruptive and post-eruptive mechanism of the anti-caries effects of fluoride: is there any anti-caries benefit from swallowing fluoride?

The belief that fluoridated water reduces caries incidence by half stems from years of fluoridation studies where the caries rates of people in various fluoridated and non-fluoridated communities were compared. By their nature, the water fluoridation trials were not able to distinguish between the topical effects of the fluoride in the water and the systemic effects of the fluoride that is inevitably swallowed and incorporated into developing teeth. Some attempts have been made to estimate the contribution of systemic fluoride to the control of dental caries but researchers are discovering that the topical effects of fluoride are likely to mask any benefits that ingesting fluoride might have. In this updated review of the pre-eruptive vs. post-eruptive benefits of fluoride in the prevention of dental caries, a re-examination of the literature, which is often cited to support the notion that swallowing fluoride, either in water or in pill form, was done in recognition of the mounting evidence for the topical mechanism as being the primary mechanism for the prevention of dental caries. Maximum benefits from exposing newly erupted teeth to topical fluoride in the oral cavity may have been seriously under-estimated. This has obvious implications for the use of systemic fluorides to prevent dental caries and forces everyone working in the field to examine more closely the risks and benefits of fluoride in all its delivery forms.     

A clinical comparison of glass ionomer,resin-modified glass ionomer and resin composite restorations in the treatment of cervical caries in xerostomic head and neck radiation patients

Controversy exists as to whether there is less secondary caries at the margins of glass ionomer restorations compared with other materials that do not release fluoride. This study examined the incidence of secondary caries for three types of restorative materials in Class V restorations in xerostomic patients. The study group consisted of 45 high caries-risk adult patients who had undergone head and neck irradiation for the treatment of cancer. All were substantially xerostomic and in need of at least three restorations in the same arch. Every patient received a restoration with each of the test materials, a conventional glass ionomer (GI), a resin modified glass ionomer (RMGI) and a resin composite (C). Patients were instructed in the daily use of a neutral pH sodium fluoride gel in custom trays. Recall appointments were made at 6, 12, 18 and 24 months, and the restorations were examined for material loss, marginal integrity and recurrent caries at the restoration margin. Fluoride compliance was determined at each recall period and recorded as the percentage of recommended use during that interval. Patients were categorized at the end of the study as fluoride non-users if their average compliance was 50% or less. Those with greater than 50% compliance were categorized as fluoride users. In the latter group, no recurrent caries was found for any of the restorations, whereas a material-dependent incidence of recurrent caries was found in the fluoride non-user group. None of the GI, one RMGI and eight C restorations failed due to recurrent caries. For the fluoride non-user patients, Fishers exact test (p=0.05) showed no statistical difference between GI and RMGI but statistical differences were found among those materials and resin composite at each recall period. Recurrent caries reductions for GI and RMGI relative to C were greater than 80% in xerostomic patients not using topical fluoride supplementation.     

Indications for the use of topical sodium fluoride in areas with water fluoridation

If maximum benefit from the use of sodium fluoride compounds in reducing dental caries is expected, topical sodium fluoride therapy should not be discontinued immediately after the initiation of a water fluoridation program in the community. The most important indication for the use of topical fluorides in water fluoridated areas is in the case of children up to and including the age of sixteen in an area which has had water fluoridation in effect for eight years or less. Further reduction in caries among children as a result of topical fluoride therapy after fluoridation has been in effect for eight years has not been observed. The use of topical fluorides on adults, in fluoride or nonfluoride areas, has not been observed to be significant benefit in reducing dental caries.     

Prevention of artificial caries: effect of bonding agent, resin composite and topical fluoride application

This study investigated the effect of fluoride containing resin composites and bonding agents, as well as the topical fluoride (F) application on the inhibition of artificial caries progression by using a pH-cycling model with alternating demineralizing (pH:4.5) and remineralizing (pH:7.0) solutions. Two bonding systems (F-containing bonding system [Reactmer Bond: RB] and non-F containing bonding system [Clearfil SE Bond: SE]), two resin composites, (F-containing [Reactmer Paste: RP] and non-F containing [Clearfil AP-X: AP]) were used. A combination of each bonding agent and a resin composite, RB+RP, RB+AP, SE+RP and SE+AP, was placed in 2 x 3 x 1.5-mm cavities on root dentin of extracted molars (n=96). Specimens were subjected to pH-cycling for 6 or 12 weeks. Half of all specimens were immersed in 0.05% NaF solution for 1 minute once a day as a topical F application. After the pH cycling period, a microradiograph of each specimen was taken, and the outer lesion depth of the artificial caries was measured by means of image analyzing software. The depths of the outer lesions at different periods were analyzed by one-way ANOVA and Sheffe's test at p=0.05. The combination that received F treatment showed reduced lesion depth compared to the same combination without F application. Except for the F application group of 12 weeks, there was no significant difference in lesion depth among each bonding and composite combination (p>0.05). At week 12 with the F application, RB+RP showed the shallowest lesion compared to the other combinations (p<0.05). The results indicated that the F application reduced the progression of artificial caries. Moreover, the combination of fluoride containing bonding agent and restorative material was the most effective for the inhibition of artificial caries progression based on the 12-week experimental period with topical F application.     

Caries prevalence among adults in communities with optimal and low water fluoride concentrations

The aim of this study was to compare the dental health status of adults measured as caries prevalence in two socioeconomically similar communities with optimal and low water fluoride concentrations respectively. Other topical fluoride sources are also taken into consideration. The study is based on clinical and radiological examinations of 30-40-yr-old subjects who for all their lives have been drinking water with a fluoride concentration representative for the community. 260 individuals resident in the optimal fluoride area and 236 from the low fluoride are included in the study. The results show that caries prevalence was lower in the optimal fluoride area. Caries prevalence was higher in women than in men within both groups. The prevalence of primary caries was low but significantly higher in the low fluoride area, principally in the form of proximal caries. Caries prevalence was not influenced by other topical fluoride sources.     

Community water fluoridation and caries prevention: a critical review

The aim of this paper was to critically review the current role of community water fluoridation in preventing dental caries. Original articles and reviews published in English language from January 2001 to June 2006 were selected through MEDLINE database. Other sources were taken from the references of the selected papers. For the past 50 years community water fluoridation has been considered the milestone of caries prevention and as one of the major public health measures of the 20th century. However, it is now accepted that the primary cariostatic action of fluoride occurs after tooth eruption. Moreover, the caries reduction directly attributable to water fluoridation have declined in the last decades as the use of topical fluoride had become more widespread, whereas enamel fluorosis has been reported as an emerging problem in fluoridated areas. Several studies conducted in fluoridated and nonfluoridated communities suggested that this method of delivering fluoride may be unnecessary for caries prevention, particularly in the industrialized countries where the caries level has became low. Although water fluoridation may still be a relevant public health measure in poor and disadvantaged populations, the use of topical fluoride offers an optimal opportunity to prevent caries among people living in both industrialized and developing countries.     

Prediction of caries in pre-school children in relation to fluoride exposure

The levels of salivary mutans streptococci and caries experience were used as predictors for caries incidence in 3 groups of pre-school children from areas with different levels of natural and topical fluoride exposure. Altogether 1022 children, 4-5 years of age at baseline, were examined according to the WHO-criteria and followed for 2 years. The low fluoride group ( n =374) had a low fluoride level in the piped water and no topical fluoride applications: the F-varnish group ( n =442) had low water fluoride but semiannual topical applications of a fluoride varnish; the optimal fluoride group ( n =206) had an optimal level of fluoride in the drinking water and semiannual F-varnish applications. The number of salivary mutans streptococci was estimated and scored at baseline with the Strip mutans chair-side method. The sampling procedure was repeated in 337 children of the low fluoride group 3 weeks after baseline. In comparison with the low fluoride group, caries incidence was 30% and 60% lower in the F-varnish and the optimal fluoride group respectively. The caries predictive ability decreased with increasing fluoride exposure. The sum of sensitivity and specificity decreased from 151% (65%+86%) in the low fluoride group to 131% (40%+91%) in the optimal fluoride group. The positive predictive value was highest (62%) in the low fluoride group. Repeated salivary samplings at baseline did not improve the caries predictive power. The results suggest that the overall fluoride exposure should be taken into account when caries risk assessment strategies for preschool children are developed and implemented.     

Fluoride exposure combinations and caries in permanent dentition among Finnish children

Abstract A representative sample (2865 persons, 7–16 years old) of children visiting municipal denial clinics was studied. Caries diagnoses were made by local dentists; structured questionnaires were used to collect data on fluoride and sugar exposures. Fluoridated pipe water was used by 26% of the children, 63% had supervised fluoride rinses and/or paintings, and 69% used fluoridated dentifrice. Water fluoridation prevented caries best. No major differences were observed between single and combined applications of different topical fluoride preventive measures as they are applied in everyday practice.     

Evaluation of appropriate use of dietary fluoride supplements in the US

Recent epidemiologic and related evidence suggests the following trends: 1. the prevalence of caries continues to decline in children of the US and several other developed countries; 2. the prevalence of mild dental fluorosis is increasing; 3. the majority of the cariostatic effects of fluoride are topical; and 4. dietary fluoride supplements are a risk factor for dental fluorosis. These trends, and the scientific evidence on fluoride and fluorosis, suggest that it is time to re-evaluate the use of dietary fluoride supplements. This paper examines the evidence for each of the four trends and the use of fluoride supplements in caries prevention today.     

The use of fluoride varnish in children: a critical review with treatment recommendations

This paper expands upon the recent report of the expert panel commissioned by the American Dental Association's Council on Scientific Affairs by offering evidence-based clinical recommendations for professionally applied topical fluoride. The authors strongly support the panel's recommendation that clinicians should rely upon caries risk criteria for determining those children who will receive a topical fluoride treatment. In this paper, the authors will take a position that when clinicians have made a decision to use topical fluoride therapy, fluoride varnish should be the only consideration for children ages 0-6 and children of all ages who have special health care needs that limit their attention span and/or cooperation. The authors offer an accompanying rationale based on dosage reduction and efficacy, that fluoride varnish should be the topical fluoride of choice for children ages 6-12. The authors expand upon the recent panel recommendations by examining published clinical trials to determine the best clinical techniques for varnish use. The authors offer clinicians the following recommendations prior to varnish use: a pre-application rubber cup or tooth brush prophylaxis, the application of varnish to dry teeth and post-operative instructions to include both no tooth brushing and a soft diet for 12 hours.