Professionally Applied Topical Fluoride

Lecture outline Introduction Fluoride solution, gels, and foams Fluoride varnish Slow release fluoride devices Recommendations for practice

Introduction

Methods for fluoride delivery Fluoridated water. Fluoridated foods (salt, milk). Fluoride supplements. Home applied topical fluoride. Fluoride in dental materials. Professionally applied fluoride.

Systemic vs. Topical Fluoride incorporated during tooth development is insufficient to play a significant role in caries prevention. The topical effect of fluoride surrounding the enamel is most important.

Professionally applied fluoride A variety of fluoride compounds and different delivery methods have been used over since as early as the 1940s.

Professionally applied fluoride The caries-preventive impact of a certain modality depends on: Type of fluoride compound Concentration of fluoride Rate of clearance from plaque solution Frequency of application

Fluoride solutions, gels, and foams

Fluoride solution Earliest form of professionally applied topical fluoride (1940s). The first preparation was 2% sodium fluoride in an aqueous solution (NaF). Applied 4 times at weekly intervals. Targeted the ages of 3,7,10,13. The solution was stable and had a bland taste. Patient recall was an issue.

Fluoride solution The second preparation was 8% stannous fluoride (SnF) Applied every six months. Solution was unstable, active for only 5-8 hours. Poor taste Caused staining and gingival irritation. The third preparation was 1.23 acidulated phosphate fluoride (APF). Applied every six months Needs to be kept in plastic containers Acidic taste

No longer recommended, as better forms of delivery are available Fluoride solutions No longer recommended, as better forms of delivery are available

Fluoride gels Developed in the 1960’s. Usually it is 1.23% (12,300 ppm) APF (Acidic). Methyl-cellulose and hydroxy-ethyl used as a “gelling agents”.

Fluoride gels The acidity leads to dissolution of hydroxyapatite and formation of Fluorapatite. Rapid uptake of fluoride happens in the first four minutes.

Fluoride gels The acidity can cause etching of composite restorations Neutral NaF 2% (9200 ppm) alternative can be used. Allows application to all teeth surfaces at once. Systemic ingestion is not uncommon: High concentration of fluoride. Large amount of fluoride can be retained in mouth following application. 78% of the dose swallowed if saliva ejector is not used. Reports of nausea and gastric irritation. comparable surface FHA deposition, but according to research evidence, achieves the same caries protection as APF.

Fluoride gels - evidence Permanent teeth: Good evidence that gels can help prevent caries in children (DMFS prevented fraction= 28%) Primary teeth: Low quality evidence that gels can help prevent caries in (dmfs prevented fraction= 20%) Adverse effects: Poor reporting. (Marinho et al., 2015)

Fluoride gels - application Patient selection: Moderate or high caries risk 7 years or older Preparation: Prophylaxis No evidence it is necessary. Select appropriate disposable plastic tray. Sit patient upright. Apply saliva ejector to reduce ingestion. Wipe teeth with gauze and air-dry.

Fluoride gels - application Apply no more than 2–2.5 grams of gel per tray (40% of the tray's volume). Upper and lower trays could be inserted separately or together.

Fluoride gels - application Keep the gel applied for 4 minutes. Ask the patient to spit the gel out for 1-2 minutes afterwards. Instruct the patient to not rinse, eat, or drink for at least 30 minutes.

Fluoride Foams Similar compound to that used in gels (APF). Similar application procedure. Requires only one fifth of amount by weight, potentially reducing amount ingested.

Fluoride Foams - evidence Little research on their use. Permanent teeth: Enamel F uptake Equivalent to that of gels. Bi-annual application reduced the incidence of caries in smooth surfaces of 6s. Application during orthodontic treatment reduced the development of white spot lesions. Primary teeth: Bi-annual application was effective in reducing caries increment.

Fluoride varnish First developed in the 1960s. Since then it was used to reduce the risk of dental caries, erosion, and sensitivity. Adheres to tooth surfaces, which prolongs contact time between fluoride and enamel (up to 48 hours). Different commercial brands available with different flavours and colours: 5% NaF - 2.26% F (22,600) Duraphat 1% Difluorosilane - 0.1% F Fluor Protector 5% NaF - Cavity Shield

Fluoride varnish Example: Duraphat varnish 2.26% w/w, 22,600 ppm F- 50mg/ml 10 ml tubes. 3 year shelf life, 3 months after opening. Costs 0.5 dinar per application.

Fluoride varnish - Evidence Permanent teeth Moderate evidence that varnish can help prevent caries (DMFS prevented fraction= 48%) Primary teeth Moderate evidence that varnish can help prevent caries (dmfs prevented fraction= 33%) No significant association with caries severity, exposure to fluorides, prior prophylaxis, concentration, or frequency of application. Not enough studies reporting on adverse effects. (Marinho et al 2013)

Fluoride varnish - Evidence One study reported that varnish is more acceptable than foams, especially among 3 to 6 year olds (Hawkins et al., 2004). Insufficient evidence to determine whether varnishes are more effective in caries prevention than gels (Marinho et al., 2003). Low-quality evidence that fissure sealants remains better than fluoride varnish for preventing occlusal caries in permanent molars (Ahovuo-Saloranta et al., 2016)

Fluoride varnish - Equipment

Fluoride varnish - Method of application Dry tooth surface before application, ideally, tooth should also be clean. Use sparingly for local application with a brush, can also use floss to deliver interdentally. Patient to avoid chewing for up to 4 hours. Patients should not brush their teeth for the rest of the day.

Fluoride varnish Dose Primary dentition: up to 0.25mls Mixed dentition: up to 0.40mls Permanent dentition: up to 0.75mls Contraindications (as per manufacturer): Hypersensitivity to colophony and/or any other constituents. Ulcerative gingivitis. Stomatitis. Bronchial asthma.

Fluoride varnish - Practical tips Very high fluoride content. Don’t use in combination with any other fluoride applications. Risk of toxic effects: Acute fluoride poisoning (5 year old, 20 kg) only 0.9 ml needed Lethal dose (5 year old, 20 kg) 13 ml needed

Fluoride varnish - Practical tips Very high fluoride content. Don’t use in combination with any other fluoride applications. Risk of toxic effects: Acute fluoride poisoning (5 year old, 20 kg) only 0.9 ml needed Lethal dose (5 year old, 20 kg) 13 ml needed

Two fluoride rinses

Two fluoride rinses Marketed in North America. APF and stannous fluoride mix. F- concentrations are low compared to gels or varnish (1,500 – 3,00 ppm) Metallic taste and increased risk of ingestion.

Two Fluoride Rinses - Evidence No evidence for effectiveness. Not recommended for use because other established modalities are already available

Slow release fluoride devices

Slow release fluoride devices A device attached to the sides of one or more tooth. Release F over several years in the oral environment. Aim to provide F in the oral cavity at low levels for a long duration. Leeds developed

Slow release fluoride devices Co-polymer membrane: contains NaF in co-polymer matrix. kept in a SS retainer attached to orthodontic band. Depending on the amount of F, these devices can release between 0.02 and 1.0 mg F/day for up to 180 days.

Slow release fluoride devices Glass device: Bead, kidney shaped (better retention), or replaceable disk. Attached to the buccal surface of the first permanent molar using adhesive resins. Contain 13.3% to 21.9% F. Releases F for up to two years.

Slow release fluoride devices - evidence Only one good RCT to assess them Good caries preventive impact in children that retained the device over the course of the study. Almost 50% of the participants lost their devices – retention is an issue. (Chong et al., 2014) Leeds developed

Recommendations for practice

Sources Public Health England (PHE) Scottish Intercollegiate Guidelines Network (SIGN) American Academy of Pediatric Dentistry (AAPD) European Academy of Paediatric Dentistry (EAPD)

Recommendations for practice Varnish and Gels are the methods supported by the strongest evidence. Application should be according to patient age, caries risk, other sources of fluoride. Example risk groups: Patients at high risk for caries on smooth tooth surfaces. Patients at high risk for caries on root surfaces. Orthodontic patients. Patients undergoing head and neck irradiation. Patients with decreased salivary flow. Children whose permanent molars should, but cannot, be sealed.

PHE Guidelines – Professional fluoride application Age Low risk High risk Professional fluoride application 6 months - 3 years None Apply fluoride varnish to teeth two or more times a year 3-16 years Apply fluoride varnish to teeth two times a year 16+ years

4 year old child Prevention?

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