A Critique of Topical Fluoride Methods (Dentifrices, Mouthrinses, Operator-, and Self-applied Gels) in an Era of Decreased Caries and Increased Fluorosis Prevalence

Within the last 20 years there has been a decrease in the caries prevalence of US schoolchildren, a change in the intraoral caries pattern, and a slowing of the progress of lesions. Simultaneously, the prevalence of enamel milder, cosmetically acceptable forms and is more noticeable in fluoride-deficient communities than those with optimal or above-optimal water fluoride concentrations. Circumstantial evidence indicates that a principal contributor to the caries decline is the extensive use of fluoride dentifrices. Conversely, although use of a fluoride dentifrice can add to the total daily amount of ingested fluoride in preschool children, there is little evidence to suggest that dentifrice ingestion is a principal factor causing the fluorosis increase. The value of fluoride methods may be assessed in relative or absolute terms. The relative, or percentage, caries reduction attributed to fluoride mouthrinses and gels appears to be a property intrinsic to the methods themselves and generally is little affected by the caries activity of the population being treated. Conversely, the absolute, or numerical, caries reduction is dependent upon the level of disease in the population. Thus, the reported caries decline reduces the number of surfaces prevented from developing caries, even though the percentage reduction remains substantially unchanged. Although inadvertent ingestion of fluoride can result from the use of mouthrinses and gels, there is little evidence to suggest that they have contributed to the fluorosis increase. When using topical methods, prudence should prevail to avoid ingestion of fluoride. Fluoride dentifrices should continue to be used routinely, and although lower potency dentifrices may be considered, the literature does not provide strong support for their need. Use of fluoride mouthrinses and gels for individual patients should be predicted upon their caries activity or risk. Use of these methods in public health programs is a matter of cost-effectiveness, which will be influenced by the caries prevalence of the target population.