Harness the Benefits of Fluoride

Introduction

Although visiting the dental office might not be among most people’s top 10 favorite activities, there are many things to appreciate when patients see their dentist. Dentists are kind, compassionate people who truly care about their patients. Patients leave with clean, smooth teeth, no stain, and often a new toothbrush and toothpaste — perfect for their overnight bag. However, no one loves leaving your chair with a new “cavity.”

Carious lesions are often preventable. While we cannot follow patients around to watch their diet and monitor their self-care routines to prevent future caries, we can provide them with in-office treatments and therapies for at-home use that will greatly reduce their caries incidence. The most effective and extensively studied treatments and therapies to prevent caries include fluoride as an active ingredient.

Yes, fluoride remains the gold standard for caries prevention and it can remineralize those areas we used to just watch. By applying fluoride varnish in-office, prescribing a fluoride rinse, or dispensing a 5,000 ppm prescription fluoride toothpaste, we can do more than watch the lesion get bigger, we can arrest current lesions and prevent future caries.

Using fluoride varnish in-office and dispensing 5,000 ppm fluoride prescription toothpaste will show your patients you care about them — giving them another reason to love visiting your practice.

— Phyllis A. Martina, RDH, MBA
Senior Professional Education Manager 
Colgate Oral Pharmaceuticals

An integral part of comprehensive dental care, fluoride’s use is as diverse as the people who benefit from it. Fluoride has been extensively studied for many years, and the research clearly shows that its benefits far outweigh its risks.

A naturally occurring mineral present in food, water, and within the human body, fluoride is primarily stored in teeth and bones, with any excess being excreted through urine.¹ An in-depth knowledge of the variety of benefits offered by different types of fluoride is important so oral health professionals can best advise their patients. Choosing the most appropriate fluoride source is highly dependent on individual patient characteristics. Since every person is unique, so too are his or her dental care needs.

Understanding patients’ levels of oral health literacy can help encourage the use of fluoride among those who may be hesitant. However, explaining the risks of fluoride use is also key to providing safe and ethical treatment.

Underserved Populations

Untreated dental caries is a public health issue and a growing concern in poor and underserved communities.² Dental caries correlates with socioeconomic status and its prevalence is higher among underprivileged and disadvantaged communities.

Dental caries is also a global issue, disproportionately affecting impoverished and marginalized populations that often have limited access to preventive measures and dental services.³

Clinical Recommendations for Fluoride Use

Effective plaque control is vital for preventing dental caries. Because many young children do not possess the necessary manual dexterity and sustained focus to brush adequately and for the time necessary, they may not remove sufficient levels of biofilm.⁴ This puts young children at an increased risk for tooth decay.

A caries risk assessment should be conducted to identify patients’ individual risk factors. Various caries risk assessment forms are available to aid clinicians in evaluating both protective and risk factors, which helps in assigning a risk level (Table 1 provides a list of resources for caries risk assessment forms). These risk levels include:

1. Low
2. Moderate
3. High
4. Extreme (high risk with hyposalivation)

Determining the risk level indicates the likelihood of future caries development and supports decision-making regarding the treatment, control, and prevention of caries lesions.⁵

After determining a patient’s caries risk level, individualized, evidence-based recommendations should be provided. The proper use of fluoride, applied at the correct concentrations and times, is beneficial.⁶

Fluoride Therapies

Except for children younger than age 2, patients of all ages should brush with a fluoride toothpaste and, for those at low caries risk, this may be enough in combination with consuming fluoridated water and limiting fermentable carbohydrate consumption. Over-the-counter fluoride mouthrinse is another helpful addition to the caries-prevention armamentarium.

Topical fluoride treatment, such as prescription fluoride dentifrice, fluoride varnish, fluoridated water, and fluoride supplements, can be used to prevent caries.^7-9 Patients of all ages can benefit from professionally applied or dispensed topical fluoride treatment.

Professionally dispensed fluoride is available in prescription fluoride dentifrice and mouthrinse, drops, and tablets. Prescription-strength fluoride toothpaste is most commonly used as it’s easy to incorporate into oral self-care routines and is effective against root caries, xerostomia, and dentinal hypersensitivity. It can be used by patients ages 6 and older at high caries risk. The protocol for using prescription toothpaste includes:⁶

• Apply a slim ribbon of prescription fluoride toothpaste at night.
• Brush thoroughly for 2 minutes after flossing.
• Do not rinse, drink, or eat following brushing to ensure maximum fluoride uptake.

Professionally applied topical fluoride varnish contains the highest concentration of fluoride, ranging from 9,000 ppm to 22,600 ppm and is administered by an oral health professional.

Fluoridated water delivers low levels of fluoride continuously throughout the day, optimally at 0.7 ppm, and is the most cost-effective method of fluoride delivery.

The recommendation for fluoride drops and tablets depends on the fluoride level in a patient’s water supply. Table 2 provides a fluoride supplementation schedule for children.

Benefits of Fluoride

Research has continuously demonstrated that topical fluoride offers many benefits. Among these is its ability to remineralize tooth structure (enamel and dentin) and arrest or delay early caries, also known as incipient decay.¹⁰ Evidence supports fluoride’s ability to improve the oral health of communities regardless of age, education, or socioeconomic status.¹¹

Another advantage is fluoride’s ability to inhibit the growth of caries-causing bacteria.¹⁰ By effectively inhibiting the enolase enzyme found in oral bacteria, fluoride reduces the growth and number of bacteria in the oral cavity.¹² Consequently, the reduced numbers of caries-producing bacteria help slow down the progression of demineralization and tooth decay.

Extensive research demonstrates the efficacy of professionally applied and dispensed fluoride use for patients of all ages in the quest to prevent and arrest dental caries as well as mitigating dentinal hypersensitivity. Ekstrand¹³ evaluated evidence on whether prescription fluoride dentifrice (containing more than 1,500 ppm fluoride) was effective at preventing root caries among older adults. Available data demonstrated that prescription fluoride dentifrice is more protective against root caries in older patients than traditional fluoride toothpastes. The research also showed that the prescription fluoride dentifrice performed better at preventing coronal caries among young patients than traditional fluoride toothpastes.

A systematic assessment and review by Garcia et al¹⁴ demonstrated that topical fluoride varnish is a safe and effective treatment for the prevention of dental caries in children. A study by Dantas et al¹⁵ involving adults with dentinal hypersensitivity along the cervical margins who received several professional applications of fluoride varnish experienced a significant reduction in pain and sensitivity from mechanical and thermal stimuli. Another advantage to using topically applied fluoride varnish is its ease of use (no messy, bulky trays) and efficient application. This can make fluoride varnish more attractive to young children and adolescents.¹⁶

Research also shows that fluoridated water decreases caries risk.^17,18 The United States Centers for Disease Control and Prevention (CDC) named community water fluoridation as one of the 10 most important public health achievements of the century.¹¹ Studies show that regular exposure to low levels of fluoride in water helps prevent caries, lowering the incidence by 25% in both children and adults. Additionally, studies reveal that children living in fluoridated communities have 2.25 fewer decayed teeth compared to those in nonfluoridated areas.¹⁹

Besides prescription dentifrice, varnish, and water fluoridation, silver diamine fluoride (SDF) is another effective form of topical fluoride treatment. In a systematic review by Hendre et al,²⁰ SDF was found to be highly effective in arresting and preventing root caries, treating hypersensitive dentin, and remineralizing deep pits and fissures on the occlusal surfaces of posterior teeth in older adults. SDF combines the antibacterial properties of silver with the enamel-strengthening benefits of fluoride to halt the progression of caries. However, the potential staining of treated lesions may dissuade some patients/​caregivers due to esthetic concerns.²⁰

Risks of Fluoride

When ingested in large quantities, fluoride can cause dental fluorosis: white, lacy lesions or spots on the developing teeth of young children under the age of 8.²¹ Unless it is a severe case that increases tooth porosity, fluorosis is asymptomatic and does not adversely affect the function of the teeth. Most cases are mild and do not require treatment.

In a systematic review and analysis conducted by Mascarenhas,²² the reported adverse events (AEs) related to the use of fluoride varnish in children were minor; approximately 65 AEs were reported between 2010 and 2019 and none resulted in death. Although no deaths were reported, five AEs were serious enough to necessitate hospitalization. Some of the signs and symptoms reported were swelling, itching, burning, rash, vomiting, difficulty breathing, and tightening of the throat. One patient reported losing consciousness.

According to Srivastava and Flora,²³ when optimal levels of fluoride have been exceeded and large quantities have been ingested over time, skeletal fluorosis poses a serious threat.

Oral health professionals need to evaluate each patient’s caries risk and ascertain his or her exposure to other fluoride sources to ensure the appropriate amount of fluoride is used. All forms of fluoride should be considered including fluoridated water, toothpaste, mouthrinse, food, drinks, and any professionally dispensed fluoride products. Young children should always be supervised when brushing their teeth to avoid over-ingestion.⁷

Cost-Effectiveness

Research supports the cost-effectiveness of using fluoride to prevent tooth decay. A recent update to a previously published systematic review confirmed that community water fluoridation is a cost-effective approach to caries prevention. Conducted in 2014, the analysis found that communities with water fluoridation consistently had lower dental costs. The six cost-benefit studies showed annual per capita intervention costs ranging from $0.11 to $4.92 for communities with at least 1,000 people, and annual per capita benefits ranging from $5.49 to $93.19. The benefit-cost ratios ranged from 1.12:1 to 135:1, with higher ratios associated with larger community populations.²⁴ These results demonstrate that the economic benefits of community water fluoridation outweigh the intervention costs, with higher benefit-cost ratios observed in larger communities.

Norrie and Pharand²⁵ looked at the cost-effectiveness of fluoride varnish application among low-income children in a Canadian daycare center. Results showed a savings of $822.98 per child over 5 years for the children who received varnish vs those who did not. Among the varnish group, 4.38 caries lesions were avoided per child, providing a savings of $187.71 per lesion.²⁵

Anti-Fluoride Activism

While fluoride is safe and effective when used correctly and in proper doses, a community of activists has emerged that is trying to end community water fluoridation. Many of the claims are politically driven, and the evidence presented is often taken out of context.

Dental and medical professionals should be prepared to refute misconceptions about fluoride.^26,27 According to the CDC, research has not demonstrated associations between fluoride use and increased risk for cancer, heart disease, immune disorders, osteoporosis, Down syndrome, or renal disorders.²⁸

Conclusion

Professional fluoride treatments offer a range of benefits for both children and adults. Fluoride helps prevent caries by making the tooth more resistant to acid erosion and acid attacks from plaque bacteria and sugars. It can also help reverse many incipient lesions.^7,15 In children age 6 +, fluoride continues to be incorporated into the formation of permanent teeth as long as the enamel is developing, making it difficult for acids to demineralize the teeth. Additionally, fluoride speeds up remineralization and disrupts acid production in already erupted teeth of children, adolescents, and adults.

For adults, new research indicates that topical fluoride is as important in fighting tooth decay as it is for strengthening developing teeth. Evidence supports the use of fluoride as a safe and effective treatment in fighting caries-producing bacteria, treating cervical dentine hypersensitivity, and arresting incipient tooth lesions, leading to stronger enamel and better protection against dental caries.^10,14,19

The frequency of a fluoride application is dependent on the caries risk level for each individual. These evidence-based findings collectively demonstrate the safety and significant benefits of professional fluoride treatments for both children, adolescents, and adults in promoting and maintaining good oral health.

References

1. Cleveland Clinic. Fluoride. Available at: http/​​​:/​​​/​​​my.clevelandclinic.org/​​​health/​​​treatments/​​-fluoride. Accessed June 28, 2024.
2. United States Centers for Disease Control and Prevention. Disparities in Oral Health. Available at: cdc.gov/​​​oralhealth/​​​or_​​​l_​​​health_​​​disparities. Accessed June 28, 2024.
3. World Health Organization. Sugars and Dental Caries. Available at: https:/​​​/​​​iris.who.int/​​​bitstream/​​​handle/​​/​​츕/​​​WHO-NMH-NHD-17.12-eng.pdf. Accessed June 28, 2024.
4. Govindaraju L, Gurunathan D. Effectiveness of chewable tooth brush in children-A prospective clinical studyJ J Clin Diagn Res. 2017;11:ZC31-ZC34.
5. Fehrenbacher JE. Focus on caries prevention. Dimensions of Dental Hygiene. 2022;20(2):26-28.
6. Hunt A, Tolle SL. The keys to caries management. Dimensions of Dental Hygiene. 2023;21(2):18-23.
7. American Academy of Pediatric Dentistry. Fluoride Therapy. Available at aapd.org/​​​globalassets/​​​media/​​​policies_​​​guidelines/​​​bp_​​​fluoridetherapy.pdf. Accessed June 28, 2024.
8. Abdollahi A, Jalalian E. Effectiveness of two desensitizer materials, potassium nitrate and fluoride varnish in relieving hypersensitivity after crown preparation. J Contemp Dent Pract. 2019;20:489-493.
9. American Academy of Pediatric Dentistry. Fluoride Use in Caries Prevention in the Primary Care Setting. Available at: aapd.org/​​​globalassets/​​​media/​​​policies_​​​guidelines/​​​bp_​​​fluoridetherapy.pdf. Accessed June 24, 2024.
10. Gao SS, Zhang S, Mei ML, et al. Caries remineralisation and arresting effect in children by professionally applied fluoride treatment – a systematic review. BMC Oral Health. 2016;16:12.
11. United States Centers for Disease Control and Prevention. About Community Water Fluoridation. Available at: gov/​​​fluoridation/​​​about/​​​index.html#:~:text=CDC%20named%20fluoridation%20of%20drinking,water%20fluoridation%20started%20in%201945. Accessed June 28, 2024.
12. Mitsuhata C, Puteri MM, Ohara Y, Tatsukawa N, Kozai K. Possible involvement of enolase in fluoride resistance in Streptococcus mutans. Pediatric Dental Journal. 2014; 24(1):12-16.
13. Ekstrand KR. High fluoride dentifrices for elderly and vulnerable adults: does it work and if so, then why? Caries Res. 2016;50:15-21.
14. Garcia RI, Gregorich SE, Ramos-Gomez F, et al. Absence of fluoride varnish–related adverse events in caries prevention trials in young children. Available ​at cdc.g_​v/​​​pc_​​/​​​issu_​​​s/​​떑/​​葜_​​꼤_​​​old.htm. Accessed June 28, 2024.
15. Dantas EM, de Oliveira Amorim FK, de Oliveira Nobrega FJ, Dantas PMC, Vascocelos RG, Queiros LMG. Braz Dent J. 2016;27:1.
16. Turchetta A . Three ways dental hygienists can boost acceptance of fluoride varnish for adults. Available at: dentalecon/​mi/​​s./​​​om/​​​science-tech/​​​article/​​묈/​​䁱-ways-dental-hygienists-can-boost-acceptance-of-fluoride-varnish-for-adults. Accessed June 24, 2024.
17. Griffin SO, Regnier E, Griffin PM, Huntley V. Effectiveness of fluoride in preventing carJ s in adults. J Dent Res. 2007;86:410–415.
18. Iheozor-Ejiofor Z, Worthington HV, Walsh T, et al. Water fluoridation for the prevention of dental caries. Cochrane Database Syst Rev. 2015;2015:CD010856.
19. The Community Guide. Dental Caries (Cavities): Community Water Fluoridation. Available at: thecom/​unit/​​guid/​​​.org/​​​findings/​​​dental-caries-cavities-community-water-fluoridation.html. Accessed June 28, 2024.
20. Hendre AD, Taylor GW, Chávez EM, Hyde S. A systematic review of silver diamine fluoride: Effectiveness and application in older adults. Gerodontology. 2017;34:411-419.
21. American Academy of Pediatrics. Fluorosis Facts: Information for Parents and Caregivers. Available at: healthychi/​dr/​​n./​​​rg/​​​English/​​​healthy-living/​​​oral health/​​​Pages/​​​Fluorosis-Facts-Information-Parents-Caregivers.aspx. Accessed June 24, 2024.
22. Mascarenhas AK. Is fluoride varnish safe? Validating the safety of fluoride vJ nish. J Am Dent Assoc. 2021;152:364-368.
23. Srivastava S, Flora S. Fluoride in drinking water and skeletal fluorosis: a review of the global impact. Curr Environ Health Rep. 2020;7:140–146.
24. Ran T, Chattopadhyay SK, Community Preventive Services Task Force. Economic evaluation of community water fluoridation: a community guide systematic review. Am J Prev Med. 2016;50:790-796.
25. Norrie O, Pharand L. Cost effectiveness of a fluoride varnish daycare program versus usual care in central winnipeg, canada. Can J Dent Hyg. 2020;54:68-74.
26. Nowak B, Sicilio L, Kizior C, Tedder G, Zimmerman N, Bobo N. Advocating for oral health through fluoridation. NASN Sch Nurse. 2019;34:288-294.
27. American Fluoride Society. Common Fluoridation Myths Answered. Available at: https:/​​​/​​​americanfluoridationsociety.org/​​​debunking-anti-claims/​​​myths. Accessed June 24, 2024.
28. United States Centers for Disease Control and Prevention. Fact Sheet: Community Water Fluoridation. Available at: cdc.gov/​​​fluoridation/​​​resources/​​​community-water-fluoridation-fact-sheet.html. Accessed June 28, 2024.

From Decisions in Dentistry. August/September 2024; 10(5):28-31