Prevention of Dental

Caries(2)
By: Dr. Yosra Abdelfatah Ali
3.Fluoride and caries control
Systemic Fluoride Professionally-applied topical
•Community water Fluoridation fluoride
•Dietary fluoride supplements •Gel
•Other methods of providing fluoride •Foam
Topical Fluoride •Varnish
Self applied •Slow releasing fluoride devices
•Fluoride containing Dentifrices •Mousse/Tooth Mousse Plus
•Fluoride rinse
Topical fluoride
•Professional topical fluoride treatments should be based on caries
risk assessment.
•Children at moderate caries risk should receive a professional
fluoride treatment at least every six months
•Those with high caries risk should receive greater frequency of
professional fluoride applications (every three to six months).
 Topical fluoride
Factors that should be considered before committing to a fluoride regimen
include:
1- Caries risk: high, medium, low.
2-Cariogenicity of the diet/oral clearance rate.
3-Patient age and compliance.
4-Use of systemic and topical fluoride modalities.
5-Community water fluoridation levels.
6-Existing medical conditions.
Self applied topical fluoride
Fluoride containing dentifrices (Toothpastes)
Fluoride rinse
Toothpastes
•They usually contain 1000 or 1450 ppm fluoride.
•The fluoride is in the form of sodium fluoride, sodium
monofluorophosphate (MFP), a combination of both, amine fluoride,
or stannous fluoride.
•There are many different brands to suit all tastes.
Toothpastes
•There is a balance between caries risk and fluorosis risk..
•Children younger than 6 years are more likely to ingest some or all of
the tooth paste used.
•Ingestion of excessive amounts of fluoride can increase the risk of
fluorosis. This excess can be minimized by limiting the amount of
toothpaste used and by storing toothpaste where young children
cannot access it without parental help.
•High-concentration fluoride toothpastes containing 2800 and 5000
ppm fluoride are now available on prescription only for high-caries-
risk patients.
 Fluoride mouth rinses
•The most common fluoride compound used in mouth rinse is sodium fluoride.
•These can be either daily rinses containing 0.05% (225ppm) sodium fluoride or
weekly rinses containing 0.20% (900ppm) sodium fluoride.
•Caries reductions of 20– 50% have been reported for fluoride rinse studies.
The effect of toothbrushing and rinsing with fluoride has been shown to be
additive.
•All orthodontic patients should be using a daily fluoride rinse to minimize the
risk of demineralization and white spot lesions.
•Children under the age of 6 years should not be recommended to use fluoride
mouth rinses because of the increased risk of swallowing the product.
Professionally-applied topical fluoride
Fluoride gel
Fluoride foam
Fluoride varnish
Slow releasing fluoride devices
Mousse/Tooth Mousse Plus
 Indications for use of professionally applied topical fluorides

•Patients who are at high risk for caries on smooth tooth surfaces
• Patients who are at high risk for caries on root surfaces
• Special patient groups, such as:
Orthodontic patients
Patients undergoing head and neck irradiation
Patients with decreased salivary flow
Children whose permanent molars should, but cannot, be sealed
•Not recommended for patients with low caries risk who reside in communities with
optimal fluoridation
Fluoride gels
•These can be applied in trays or by brush, and 26% caries reductions
have been reported.
•They are high in fluoride (1.23% = 12 300ppm) for professional use
and lower (1000ppm) for home use.
There is a risk of toxicity with the high-fluoride gels and the following
safety recommendations should be followed:
• No more than 2mL per tray
• Sit patient upright with head inclined forward
• Use a saliva ejector
• Instruct the patient to spit out for 30 seconds after the procedure
(older gels have to be applied for 4 minutes but newer gels only 1
minute)
• Do not use for children under 6 years.
•Home-use gels contain 1000–5000ppm fluoride for use by patients
at home at bedtime in addition to toothbrushing. Caries reductions
of 36% have been reported.
Stannous fluoride Gel
•0.4%
•It reacts with the hyroxiapatite forming stannous trifluorophosphate
crystals which is more resistant to caries
•It has many disadvantages:
1-Metallic taste
2-Staining of tooth and marginal restorations
3-Unstable
 Acidulated phosphate fluoride Gel
•Concentration: 1.23% (12,30ppm)
•It has PH of 3.5
•Advantages :
1- Acceptable taste
2- No staining or gingival irritation
•Disadvantage:
It may damage porcelain restorations
Sodium fluoride Gel
•Concentration: 2% (9000ppm)
•Has a ph of 7
•It has Used in patients with
Esthetic restorations
Reduced salivary flow
Those who cannot tolerate acidic fluoride
 Fluoride foam

It is available as :
*NaF 2% *APF 1.23%
It does provide the benefit of requiring a smaller amount for
application, resulting in a lower fluoride dose and thereby
reducing the risk associated with inadvertent ingestion.
Four-minute fluoride foam applications, every six months
are effective in caries prevention in the primary dentition
and newly erupted permanent first molars.

Six-monthly professional application of APF foam could

effectively reduce the incidence of dental caries in smooth
surfaces of permanent first molars in 6–7-year-old
children, which was similar to APF gel.
 Application of fluoride gels and foam
Patient sit in the upright position with the head tipped slightly
forward allowing excess saliva and fluoride to flow toward the lip .
 Use saliva ejector
The tray should be one third full for gel and half full for foam
No need for prophylaxis
Application time should be four minutes.
Both upper and lower trays are inserted at once to complete
the treatment in one 4 minutes application
Positive reinforcement during the procedure may be needed.
The patient shouldn’t eat ,drink or rinse for 30 minutes after
the treatment to maximize fluoride uptake in enamel .
 Fluoride varnishes
•Duraphat® (5wt% fluoride = 22 600ppm fluoride) is the most widely
available fluoride varnish. This has a very high fluoride concentration, so
there is the possibility of toxicity with young children.
•The fluoride is released relatively slowly from the varnish and therefore
the potential risks of toxicity are less than with gels.
•Caries reductions of 50–70% have been reported
•Advantages of this modality are that it is well tolerated by infants and
young children, has a prolonged therapeutic effect, and can be applied
by both dental and non dental health professionals in a variety of
settings.
 Application of fluoride varnish
Teeth are dried with a 2-inch gauze square
 The varnish is then painted onto all surfaces of the
teeth with a brush provided with the varnish.
Children are instructed to eat soft foods and not to
brush their teeth on the evening after the varnish
application to maximize the contact time of the
varnish to the tooth.
The following day, they should resume brushing
twice daily with fluoridated toothpaste.
 Fluoride Varnish Products
•Duraphat 5% sodium fluoride
-Amber colored
-Excellent choice for application
•Duraflor 5% sodium fluoride
-Sweetened with xylitol
•Duraflor Halo 5% sodium fluoride
- White tooth colored
-Flavored with mint or wild berry
-Sweetened with xylitol
-Gluten, egg, and peanut free
•Profluoride varnish 5% sodium fluoride
-Tooth colored
-Sweetened with xylitol
-Adhere well to wet surface
-Flavored
•Profluoride L varnish 5% sodium fluoride
-Transparent
-Used after bleaching
-Gluten free
 Slow-release fluoride devices
Targeting the high-caries-risk groups
There are two main types:
-Copolymer membrane type
-Glass device type

The fluoride glass devices release low levels of fluoride for at least 2 years
and have great potential for use in preventing dental caries in high-caries-risk
groups and irregular dental attenders. It is attached to buccal surface of first
permanent molar
Casein phosphopeptide-amorphous
calcium phosphate (CPP-ACP)
•A milk based protein complex stabilizing Ca2+ and PO43– and added
to topical creams (Tooth Mousse) and chewing gum.
•CPP-ACP stabilizes Ca2+ and PO43 and allows the creation of highly
supersaturated solutions of Ca2+ and PO43–, driving remineralization
of enamel via concentration gradients and maintenance of intra-oral
supersaturation relative to enamel mineral.
•The CPP-ACP is retained in the oral cavity for at least 3 hours,
providing a long-lasting source of bio-available Ca2+ and PO43– and
increasing the efficacy of any fluoride present.
•Products such as Tooth Mousse (MI Paste) should be used in children
at risk of dental caries as a preventive agent, and in those with early-
stage caries (white spot lesions) to assist remineralization.

•A fluoridated CPP-ACP cream (Tooth Mousse plus, 900ppm NaF)

improves the remineralization efficacy by approximately 25%.
However, it should generally be used in children over 10 years old to
decrease the chance of fluorosis from ingestion.
 Recommendations by age
6 to 12 months

1. Complete the clinical oral examination with adjunctive diagnostic tools (eg, radiographs
as determined by child’s history, clinical findings, and susceptibility to oral disease) to
assess oral growth and development, pathology, and/ or injuries; provide diagnosis.
2. Provide oral hygiene counseling for parents, including the implications of the oral health
of the caregiver.
3. Remove supragingival and subgingival stains or deposits as indicated.
 Recommendations by age
4. Assess the child’s systemic and topical fluoride status (including type of infant formula
used, if any, and exposure to fluoridated toothpaste) and provide counseling regarding
fluoride. Prescribe systemic fluoride supplements, if indicated, following assessment of
total fluoride intake from drinking water, diet, and oral hygiene products.

5. Assess appropriateness of feeding practices, including bottle and breast-feeding, and

provide counseling as indicated.
6. Provide dietary counseling related to oral health.
7. Provide age-appropriate injury prevention counseling for orofacial trauma.
8. Provide counseling for nonnutritive oral habits (eg, digit, pacifiers).
9. Provide required treatment and/or appropriate referral for any oral diseases
or injuries.
10. Provide anticipatory guidance.
11. Consult with the child’s physician as needed.
12. Complete a caries risk assessment.
13. Determine the interval for periodic reevaluation.
12 to 24 months

1. Repeat the procedures for ages six to 12 months every six months or as
indicated by individual patient’s risk status/ susceptibility to disease.
2. Assess appropriateness of feeding practices (including bottle, breast-feeding,
and no-spill training cups) and provide counseling as indicated.
3. Review patient’s fluoride status (including any childcare arrangements which
may impact systemic fluoride intake) and provide parental counseling.
4. Provide topical fluoride treatments every six months or as indicated by the
individual patient’s needs.
2 to 6 years

1. Repeat the procedures for 12 to 24 months every six months or as indicated

by individual patient’s risk status/ susceptibility to disease. Provide age-
appropriate oral hygiene instructions.
2. Scale and clean the teeth every six months or as indicated by individual
patient’s needs.
3. Provide pit and fissure sealants for caries-susceptible primary molars and
permanent molars, premolars, and anterior teeth.
4. Provide counseling and services (eg, mouthguards) as needed for orofacial
trauma prevention.
5. Provide assessment/treatment or referral of developing malocclusion as
indicated by individual patient’s needs.
6. Provide required treatment and/or appropriate referral for any oral diseases,
habits, or injuries as indicated.
7. Assess speech and language development and provide appropriate referral as
indicated.
6 to 12 years

1. Repeat the procedures for ages two to six years every six months or
as indicated by individual patient’s risk status/susceptibility to disease.
2. Provide substance abuse counseling (eg, smoking, smokeless
tobacco).
3. Provide counseling on intraoral/perioral piercing.
12 years and older
1. Repeat the procedures for ages six to 12 years every six months or
as indicated by individual patient’s risk status/susceptibility to disease.
2. During late adolescence, assess the presence, position, and
development of third molars, giving consideration to removal when
there is a high probability of disease or pathology and/or the risks
associated with early removal are less than the risks of later removal.
3. At an age determined by patient, parent, and pediatric dentist, refer
the patient to a general dentist for continuing oral care.
There is evidence from randomized clinical trials that 0.2 percent NaF
mouthrinse and 1.1 percent NaF brush-on gels/pastes also are
effective in reducing dental caries in children.