The Role of Fluoride in Caries Prevention

Fluoride is one of the most valuable weapons in the fight against tooth decay among pediatric patients, and sales reps play a vital role in this battle. The author explores the latest fluoride clinical guidelines.

Dental caries remains a public health concern. In the U.S., it is the most common chronic disease of childhood.1 Globally, untreated caries in primary teeth is the 10th most common chronic condition in children, impacting 621 million individuals.2 Data from the U.S. National Health and Nutrition Examination Survey 2011-2012 revealed that 23% of children between the ages of 2 and 5 and 56% of children between the ages of 6 and 8 experienced dental caries in a primary tooth.3 Among permanent dentition, 21% of children between the ages of 6 and 11 experienced dental caries.3 Of those children, 6% had untreated dental caries.3 The data also revealed that race and ethnicity play a role in dental caries prevalence among children between the ages of 2 and 8. For example, Hispanic (46%), and non-Hispanic black children (44%) had more reported dental caries than non-Hispanic white children (31%).3

Caries is preventable with proper implementation of preventive measures by parents/caregivers and dental and medical professionals, and fluoride is one of the most effective strategies for preventing tooth decay. A well-informed sales rep can use these guidelines and preventive measures as an opener for product sales success.

SOURCES OF FLUORIDE

Staying informed on various souces of fluoride will help sales reps best serve their dental clients. For those patients unfamiliar with fluoride, oral health professionals should explain fluoride is found in several sources, such as in community water sources, foods, toothpastes, mouthrinses, and professional products. Roughly, 72% of the U.S. population has fluoridated water.4 Current drinking water recommendations are 0.7 mg of fluoride/liter (mg/L) to prevent dental caries.5 It’s this concentration that provides a balance of reducing dental caries while minimizing the risk of dental fluorosis.5 Children who reside in communities with fluoridated tap water have less tooth decay than children who reside in nonfluoridated communities.1 Dentists should remind parents/caregivers that the consumption of fluoridated water reduces dental caries in about 25% of children and adults.6

Even infant formula and formula concentrate contain fluoride. In previous years, the U.S. Centers for Disease Control and Prevention (CDC) and the American Dental Association (ADA) suggested using low-fluoride water to prepare infant formula to minimize the risk of dental fluorosis.4 However, with the current reduced fluoride concentration in drinking water (0.7 ppm), the ADA supports the use of tap water to prepare infant formula.7 For this reason, clinicians should remind parents/caregivers to monitor their children’s exposure to fluoride to prevent dental fluorosis.

And fluoride is not limited to drinking water. Fluoride concentration is found in community drinking water, processed foods and beverages. A study by Martinez-Mier et al8 evaluated fluoride concentrations found in foods and beverages. Grains, meats, and fish revealed the highest fluoride concentrations, followed by fruits and dairy products.8

Sales reps will find the most potential for successful sales in manufactured sources of fluoride. These sources include toothpaste, mouthrinse, professionally applied products, and supplements. The CDC does not recommend that children younger than 2 use fluoride toothpaste unless prescribed by an oral health or medical professional.1 However, the ADA suggests that children’s deciduous teeth be brushed twice per day with a tiny smear of fluoride toothpaste as soon as they erupt. The ADA also recommends children age 3 and younger use no more than a smear or grain-of-rice-size amount of fluoride tooth­paste.9 Children ages 3 to 6 should use no more than a pea-size amount of fluoride toothpaste during toothbrushing.10 Regardless of age, oral health professionals should direct parents/caregivers to supervise young children while tooth brushing to minimize the risk of ingestion. Recommending a fluoride mouthrinse to patients is another option as this source can be effective in caries prevention for children ages 6 to 18.4 A systematic review determined that the use of a prescription-strength mouthrinse containing 900 ppm fluoride (0.09%) at least weekly reduced dental caries risk.4


Point of Sale | Prevention Strategies

  • Dental caries remains a public health concern. In the U.S., it is the most common chronic disease of childhood.1
  • Children who reside in communities with fluoridated tap water have less tooth decay than children who reside in nonfluoridated communities.1
  • Fluoride toxicity can occur if recommended doses for fluoride additives are not followed.
  • To date, fluoride varnish has overtaken acidulated phosphate fluoride gels and foams as the most common form of professional fluoride application.
  • Silver diamine fluoride (SDF) is an important new therapy in the treatment of cavitated lesions for pediatric and special-needs populations. While SDF is not used as a preventive measure for dental caries, it is commonly used to arrest dental caries in children and adults.
  • While educating primary care physicians is important, teaching parents/caregivers on caries-preventive measures is also essential.
  • There is a moderate net benefit of preventing dental caries when fluoride varnish is applied to children’s teeth beginning at the eruption of primary dentition. Thus, all children can benefit from fluoride varnish application regardless of dental caries risk.

It is wise for sale reps to advise dentists to consider a patient’s age when selecting the appropriate fluoride concentration. From the late 1960s to the early 2000s professionally applied acidulated phosphate fluoride (APF) gels and foams were the most widely used method of in-office application in the U.S as both reduce the incidence of dental caries in primary and permanent teeth.11 Practitioners should be advised the use of APF gel or foam on infants, young children, and patients with disabilities is no longer recommended due to the risk of ingestion.12 To date, fluoride varnish has overtaken APF gels and foams as the most common form of professional fluoride application.13 A panel convened by the ADA Council on Scientific Affairs recommends the application of 2.26% fluoride varnish or 1.23% fluoride APF gel, or a prescription-strength, home-use 0.5% fluoride gel or paste or 0.09% fluoride mouthrinse for patients age 6 and older who are at risk of dental caries. For children younger than 6, the panel only recommends 2.26% fluoride varnish.11

For pediatric patients at high risk for caries and who have no or suboptimal exposure to fluoride may benefit from prescribed dietary fluoride supplements.14,15 The following dietary supplement schedule is recommended when fluoride ion concentration is low in drinking water, and children are at high risk for caries (Table 1).14

Silver diamine fluoride (SDF) — while not used as a preventive measure for dental caries — is an important new therapy in the treatment of cavitated lesions for pediatric and special-needs populations. SDF is commonly used to arrest dental caries in children and adults. The American Academy of Pediatric Dentistry (AAPD) released new guidelines in 2017 on the use of SDF for dental caries in children and adolescents.16 The guidelines support the use of 38% SDF to arrest cavitated caries lesions in primary dentition.16 And dental sales reps should be prepared to answer questions on SDF, as the opportunity to sell into this new therapy exists


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Fluoride Toxicity

Fluoride toxicity can occur if recommended doses for fluoride additives are not followed. Acute fluoride toxicity is dependent on the dose-intake and a patient’s weight.17 While small ingestions of fluoride can cause gastrointestinal irritation, large amounts can lead to organ damage.18 The overconsumption of fluoride can also lead to fluorosis, skeletal fluorosis, and bony outgrowths.14,18

Elevated amounts of fluoride during enamel formation increase the risk of fluorosis. Repeated exposure of fluoride-concentrated foods and beverages early in a child’s life can increase this risk.4 Enamel defects are symptomatic of fluorosis and may present as white specks, striations, or rough pitted surfaces.4 Fluorosis can range from very mild to severe. Very mild fluorosis is often misdiagnosed because it can mimic other oral conditions such as tetracycline staining.4


FLUORIDE RECOMMENDATIONS

Based on evidence from clinical trials, meta-analyses, systematic reviews, and expert panels conducted by the AAPD, ADA, and the U.S. Preventive Services Task Force, the following recommendations can be made on the utilization of fluoride in preventing dental caries or minimizing dental caries risk among pediatric patients.10,19 Fluoride is both safe and highly effective in minimizing caries prevalence.10,19 Professionally applied topical fluoride treatments at 5% sodium fluoride (NaF) varnish or 1.23% gel preparations are efficacious in reducing caries risk in children.10 Mouthrinse containing 0.2% NaF and 1.1% NaF gels and toothpastes are effective in reducing dental caries in children.10 There is a moderate net benefit in preventing future dental caries with oral fluoride supplements beginning at six months for children whose water supply is deficient in fluoride.19 There is a moderate net benefit of preventing dental caries when fluoride varnish is applied to children’s teeth beginning at the eruption of primary dentition. Thus, all children can benefit from fluoride varnish application regardless of dental caries risk. Fluoride varnish can be applied every six months among preschool aged children who are at moderate risk for dental caries.19 Moreover, children who are at moderate risk for dental caries should receive the application every three months to six months.20 A better understanding of these recommendations will help sales reps hone their sales pitches to better align with their clients’ individualized needs.


Lexicon

Acidulated phosphate fluoride: Or APF, a sodium fluoride solution used in the prevention of dental caries. Available in gels and foams.
Caries: Tooth decay; commonly called cavities. It involves the bacterial formation of biofilm and plaque on the teeth, which contribute to acid production that demineralizes enamel and dentin, leading to caries.
Dental fluorosis: Also called mottled enamel, is a condition caused by an excessive intake of fluoride characterized by white specks in tooth enamel.
Silver diamine fluoride: This therapy, also referred to as SDF, is a minimally invasive, low-cost treatment for caries in pediatric patients.


COLLABORATIVE APPROACH

Recent trends focus on an interprofessional collaborative approach to address factors associated with caries risk and implement preventive measures. Primary care providers (PCPs) see children and their parents/caregivers the most often through well-child visits, which focus on disease prevention and the patient’s development and growth.21 Thus, oral health assessments, anticipatory guidance, and fluoride varnish application should be part of these visits. In most states, PCPs can apply fluoride varnish.22,23 However, barriers associated with performing oral health assessment include insufficient time to perform additional duties, lack of confidence in referring patients to local dentists, and inadequate training in oral health.24,25

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Performing oral health assessments, applying fluoride varnish, and making proper referrals to oral health professionals are tasks PCPs must feel confident in initiating. The American Academy of Pediatrics has several oral health education training programs to assist in increasing confidence and competence among PCPs.26 While educating PCPs is important, teaching parents/caregivers on caries-preventive measures is also essential. Oral health professionals should understand through interprofessional collaboration and education, a sound partnership and referral system can be established to improve access to care and minimize caries risk.

CONCLUSION

Both oral health and medical professionals should assess children’s caries risk and fluoride exposure at each preventive appointment. Clinicians should also educate parents/caregivers on the sources of fluoride through foods, oral health products, and professional applications. Through patient-centered interprofessional collaboration, children’s caries risk can be significantly reduced; thereby improving overall health and quality of life. Sales reps can use their knowledge in this space to arm customers with effective fluoride treatments for their pediatric patients’ individualized needs.

 

This article is adapted from one previously published in Dimensions of Dental Hygiene.

References

  1. United States Centers for Disease Control and Prevention: Children’s Oral Health. Available at: cdc.gov/oralhealth/children_adults/child.htm. Accessed January 22, 2018.
  2. Kassebaum NJ, Bernabe E, Dahiya M, Bhandari B, Murray CJL, Marcenes W. Global burden of untreated caries: A systematic review and metaregression. J Dent Res. 2015;94:650–658.
  3. Dye BA, Thorton-Evans G, Li X, Lafolla T. Dental caries and sealant prevalence in children and adolescents in the United States, 2011-2012. NCHS Data Brief. 2015;191:1–8.
  4. Carey C. Focus on fluorides: update on the use of fluoride for the prevention of dental caries. J Evid Based Dent Pract. 2014;14(Suppl):95–102.
  5. U.S. Department of Health and Human Services Federal Panel on Community Water Fluoridation. US public health service recommendation for fluoride concentration in drinking water for the prevention of dental caries. Public Health Rep. 2015;130: 318–331.
  6. U.S. Centers for Disease Control and Prevention. Community Water Fluoridation. Available at: cdc.gov/fluoridation/index.htm. Accessed January 22, 2018.
  7. Berg J, Gerweck C, Hujoel PP, et al. Evidence-based clinical recommendations regarding fluoride intake from reconstituted infant formula and enamel fluorosis: A report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc. 2011;142:79–87.
  8. Martinez-Mier EA, Spencer KL, et al. Fluoride diet of 2- year-old children. Community Dent Oral Epidemiol. 2017;45:251–257.
  9. U.S. Centers for Disease Control and Prevention. Brush Up on Healthy Teeth. (n.d). Available at: cdc.gov/OralHealth/pdfs/BrushUpTips.pdf. Accessed January 22, 2018.
  10. American Academy of Pediatric Dentistry. Guideline on fluoride therapy. Pediatr Dent. 2013;35:E165–168.
  11. Weyant R, Tracy SL, Anselmo T, Beltran-Aguilar ED, Donly KJ, Frese W. Topical fluoride for caries prevention. J Am Dent Assoc. 2013;144:1279–1290.
  12. U.S. Preventive Services Task Force. Grade Definition. Available at: uspreventiveservicestaskforce.org/Page/Name/grade-definitions. Accessed January 22, 2018.
  13. Bonnetti D, Clarkson JE. Fluoride varnish for caries prevention: Efficacy and implementation. Caries Res. 2016;50(Suppl 1):45–49.
  14. Rozier RG, Adair S, Graham F, et al. Evidence-based clinical recommendations on the prescription of dietary fluoride supplements for caries prevention. J Amer Dent Assoc. 2010;141:1480–1489.
  15. Levy SM, Guha-Chowdury N. Total fluoride intake and implications for dietary supplementation. J Public Health Dent. 1999;59:211–223.
  16. American Dental Association. New Guidelines Address the Use of Silver Diamine Fluoride in Pediatric and Special-Needs Patients. Available at: ada.org/en/science-research/science-in-the-news/new-guideline-addresses-the-use-of-silver-diamine-fluoride-in-pediatric-and-special-needs-patients. Accessed January 22, 2018.
  17. Garcia RI, Gregorich SE, Ramos-Gomez F, et al. Absence of fluoride varnish-related adverse events in caries prevention trials in young children, United States. Prev Chronic Dis. 2017;14:E17.
  18. Shah S, Quek S, Ruck B. Analysis of phone calls regarding fluoride exposure made to New Jersey poison control center from 2010 to 2012. J Dent Hyg. 2016;90:35–45.
  19. Moyer V. Prevention of dental caries in children from birth through age 5 years: US Preventive Services Task Force recommendation statement. Pediatrics. 2014;133:1102–1111.
  20. American Dental Association Council on Scientific Affairs. Professionally applied topical fluoride: evidence-based clinical recommendations. J Am Dent Assoc. 2006;137:1151–1159.
  21. American Academy of Pediatrics. Recommendations for Preventive Pediatric Health Care. Available at: aap.org/enus/Documents/periodicity_ schedule.pdf. Accessed January 22, 2018.
  22. State Medicaid Payment for Caries Prevention Services by Nondental Professionals. Avaliable at: paconnect.wpengine.netdna-cdn.com/wp-content/uploads/2013/07/AAP-OHReimbursementChart-2.pdf. Accessed January 22, 2018.
  23. Virginia Oral Health Coalition. Important Update to Fluoride Varnish Billing Code For Medical Providers. Available at: vaoralhealth.org/ WHOWEARE/News/TabId/96/ArtMID/838/ArticleID/29/Important-Update-to-Fluoride-Varnish-Billing-Code-for-Medical-Providers.aspx. Accessed January 22, 2018.
  24. Hegner R. The interface between medicine and dentistry in meeting the oral health needs of young children: a white paper. Pediatr Dent. 2005;–130.
  25. Mitchell-Royston L, Nowak A. Interprofessional study of oral health in primary care. Available at: aapd.org/assets/1/7/Dentaquest_Year_1_ Final_Report.pdf. Accessed January 22, 2018.
  26. American Academy of Pediatrics. Oral Health Education and Training. Available at: aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Oral-Health/Pages/Education-and-Training.asp. Accessed January 22, 2018.

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From MENTOR. May 2018;9(5): 22-26.

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