Section Seven

TREATMENT MODALITIES

Fluoride Utilization Chemotherapeutics Ultrasonics Instrumentation Polishing

“Well done is better than well said.”Benjamin Franklin

Fluoride Utilization

Paradigm Shift: moving from a surgical approach to dental caries to a medical approach.

Two Key Points:

1.Caries is a bacterial Infection

2.Caries is reversible

Dental Caries is an Infectious Disease.

What else is an infectious disease?

Pneumonia Eye Infections Chlamydia Ear Infections Sinusitis

When we go to the doctor with an eye infection does the Doctor recommend we “observe” or “watch” the eye infection until it is infected enough to warrant surgical removal?????

Observing demineralization, decalcification and incipient decay is no longer considered appropriate treatment planning.

The formation of dental caries is a long process starting with demineralization and continuing through to cavitation. While dental caries remains in the enamel layers, it can be CURED with medicines. (Fluoride and Xylitol). As with other diseases, early detection and treatment is crucial.

With all of the advances in dentistry, tooth decay is still the most widespread disease in the world. If keeping teeth healthy for a lifetime is the goal of a practice, there must be a shift in the Oral Care Providers perception of Fluoride utilization.

Fluoride is not solely for the prevention of dental caries. Fluoride is an appropriate and necessary TREATMENT for dental caries.

The days of the “Wait and Watch” approach to caries management are over.

Attention! High-Impact Update!

In November of 2013, the American Dental Association changed their recommendations on Fluoride Therapies.

Current ADA Evidenced-Based Clinical Recommendations are as follows:

Professionally-applied 2.26% fluoride varnish every 3 – 6 months for elevated risk patients.

Home-use prescription-strength 0.5 percent fluoride gel or paste or 0.09 percent fluoride mouth rinse (for patients 6 years old or older)

A 2.26%professionally-applied fluoride varnish every 3-6 months is recommended for children younger than 6 years old

Professional use of tray-delivered foams and gels are not recommended due to lack of evidence of benefit.

Key Points

1. For many years tray delivered fluorides of 1 to 4 minute applications have been routinely used in dentistry. There is no evidence that patients benefit from this procedure.

2. Only 2.26% NaF varnish is recommended. 5% NaF varnish is double the ADA recommendations. Almost all Fluoride varnishes available today are 5% NaF (double the recommended dose).

Professional delivery of fluoride therapies via tray-delivered foams and gels and/or rinses has no clinical evidence of benefit. This procedure has been removed from ADA recommendations. Good clinical practice and excellent customer service now includes the use of fluoride varnishes only.

What does THERAPEUTIC DOSE mean?

“The amount of medication required to produce the desired effect”.

A sponge can only soak up so much water.

A tooth can only soak up so much fluoride.

Evidenced-based clinical research shows that the therapeutic dose for fluoride varnish is about 2.5%.

Utilization of 5% Fluoride Varnish is over the recommended therapeutic dose of fluoride varnish.

Topical fluoride applications benefit adults as well as children. Clinical study results show the same protective and remineralization mechanisms that apply to children also apply to adults.

The actions of fluoride include the following:

Prevents or controls the spread of caries.

Inhibits the dissolution of calcium and phosphate in the enamel.

Remineralizes enamel. (crystal repair)

Decreases the rate of bacterial colonization and acid production.

What types of patients could benefit from fluoride treatment?

1. No fluoride in drinking water as a child.2. No fluoride in drinking water now.3. Drink filtered or bottled water.4. Have receding gums or a history of gum disease.5. Have multiple fillings and/or crowns.6. Strong family history of dental decay.7. Active ortho patients8. Use home whitening products.9. Have limited dexterity10. Use lozenges, gum, mints, hard candy with sugar.11. Visit the dental office irregularly.12. Currently undergoing (or have a history of) radiation or chemotherapy.13. Suffer from acid reflux.14. Teeth that trap food.15. Any dental work done in the past year.16. Snack frequently between meals.

17. Sip on beverages throughout day. (other than water)18. Use tobacco products of any type19. Grind teeth20. Floss less than once per day.21. Take medications that cause xerostomia (dry mouth).

What medications cause xerostomia (dry mouth)?

Virtually all medications have some oral side effect, usually dry mouth.

The Physicians’ Desk Reference contains more than 500 potential xerostomia-causing drugs!

Two types of application:

1. Topical (fluoride varnish)

2. Systemic (drinking water, oral supplements – benefit children only)

Note: TOPICAL FLUORIDE SHOULD NEVER BE INGESTED. USE MINIMUM THERAPEUTIC DOSE ONLY

Every patient in the practice could benefit from additional fluoride, which would include home and professional fluoride varnish application. Research has shown that, in order to maintain beneficial levels of fluoride on the tooth surfaces, the patient must receive an intensive professional fluoride varnish application. Home applications alone will not reach or maintain this optimum level.

Record the reasons that the patient would benefit from fluoride therapy in the patients chart to:

Enhance the clinicians ability to educate the patient about the benefits Help overcome objections to the recommended fluoride therapy

Assists in answering any insurance carrier inquiriesTo open the door for discussion about the benefits of fluoride, professional or home, clinicians may choose to use a questionnaire (CaMBRA – Caries Management By Risk Assessment). By completing the questionnaire, the patient would identify for themselves why they would be a candidate for fluoride therapy. The questionnaire can be easily completed prior to the patient being seated. The business administrator (front desk) would simply inform the patient that the doctor or the hygienist (using their names) have requested that they complete the form prior to being seen that day so that they will be prepared to better serve them as a patient. This leads to patient education and acceptance with fewer objections. Patient education is key. Once the patient understands their own individual benefit, they too, become believers of this wonderful service. Everyone’s goal of keeping teeth for a life time can come closer to becoming reality.

Root Caries

2.5 times greater potential for caries than for enamel (without fluoride therapy) Caries occurs in high pH than coronal caries Critical pH 6.7 for root surfaces Critical pH 5.5 for enamel surfaces Lesions progress rapidly Difficult to restore and maintain 91% of root caries can be arrested with topical Fluoride varnish Root surfaces are porous, therefore have greater uptake of Fluoride By age 50, 50% of adults have experienced root caries

Helpful Hint: pH is the symbol of hydrogen ion concentration expressed numerically which corresponds to the acidity or alkalinity of an aqueous solution. The range is from 14 (base) to 0 (acid). Neutral is 7. Critical pH at which demineralization occurs for enamel is 4.5 to 5.5 and for cementum demineralization occurs at 6.0 to 6.7.

Saliva is the engine, fluoride is the gas that makes it go!

The function of saliva is as follows

Lubricates oral mucosa Clears bacteria and carbohydrates Contains calcium/phosphate/fluoride – essentially prevents cavities Mediates taste acuity Buffers pH control Facilitates digestion and speech Produces salivary pellicle

Fluoride Therapy ProtocolsMost popular compounds include:

Acidulated Phosphate Fluoride 1.23% - no clinical benefit to patient Neutral Sodium Fluoride Varnish 5% (double the therapeutic dose)

Neutral Sodium Fluoride Varnish 2.5% (available from only one company)

Actual use of professional fluorides breaks down as follows:

96% of dental professionals believe that adults benefit from topical fluoride

14% of dental professionals offer fluorides to adult patients

Reasons stated: Because insurance doesn’t cover it Practitioners feel bad about charging for it It takes too much time to educate a change

Considerations when establishing fees include the following:

Prevention is better than restoration or tooth loss Patients do not value services (as much) at no fee Education builds value No offer = No acceptance

Options for Adult Fluoride Fees:

1. Charge a reasonable fee for the service of professional fluoride2. Incorporate the cost of providing professional fluoride therapy into the adult

prophy fee.3. Offer professional fluoride therapy as a way of internally marketing the practice’s

desire to have low caries at no fee. Inform patients of the fact that this is being done complementary and the value of the service (why they need it).

Treatment of Xerostomia (Dry Mouth) Protocols

1. Application of 2.5% NaF Fluoride Varnish every 3 months2. Home Therapy – RX Fluoride rinses3. Education and recommendations on saliva substitutes, Biotene, plenty of

water drinking.4. Avoidance of tobacco products- smoking cessation education.

Treatment of Hypersensitivity

The FDA has approved Fluoride for the following uses:

1. Tooth Desensitization2. Cavity Liner

*Caries prevention and remineralization is an off-label use of Fluoride*Hypersensitivity Protocol

1. Apply 2.5% Fluoride Varnish to sensitive areas2. Have patient return in 3 days for re-application of 2.5% Fluoride VarnishOR3. Recap Fluoride Applicator, educate patient on application and send remaining

2.5% Fluoride varnish home with the patient to reapply at home in 3 days.4. Repeat every 3 months as needed.

Colophony – what is it and why is it important?

Most dental varnishes available today contain colophony. Colophony is pine tree sap that has been sanitized with alcohol. This is significant to the Oral Healthcare Provider in that it is highly allergenic to those with tree, nut or pine allergies.

Most medical history forms in dental practices do not specifically ask about nut allergies, which are highly prevalent and associated with anaphylactic reactions. Colophony contains a common antigenic protein with peanuts.

Utilization of a colophony-free, 2.5% NaF varnish is essential to eliminating unnecessary exposure to allergens and inadvertent over-dosing of Fluoride.

Fluorimax TM (Elevate Oral Care) is colophony-free and 2.5%NaF. All-in-one applicator is fast and easy.

50% more Fluoride uptake than the popular “Vanish Varnish” and can be re-capped for take-home re-application for desensitization.

Example of Colophony exposure risks as reported to FDA:

OMNI ORAL PHARMACEUTICALS VANISH 5%NAF WHITE 5% VARNISH  

Back to Search Results

Event Date 11/07/2007Event Type  Injury   Patient Outcome  Life Threatening Event Description We took our son for a routine dental visit, which was his first cleaning. At this visit, they applied 'vanish varnish' made by omni oral pharmaceuticals a 3m company. Upon application of this product, my son stuck his tongue out and refused to swallow. After the treatment he continued to leave his tongue out of his mouth and to lick anything he could find. Shortly after that, he vomited violently and i noticed his tongue was swollen and whole mouth was very red. The dentist was aware that my son has an allergy to peanuts and most tree nuts and pulled the msds sheet for the product. The ingredients were as follows: ethyl, alcohol, sodium fluoride, hexanes, rosin, and flavorings. There were no allergy warnings. The dentist then called the company and they reluctantly faxed over a toxicology assessment dated 2007, that states a "risk of allergic cross-reactions to colophony contained in vanish varnish in pts with allergic reactions to pine nuts. " there were no allergy warnings on the product packaging and the toxicology report had not been distributed to the dentist. My son's reaction was potentially life threatening. A warning should be required to prevent more reactions in the future. Dates of use: one day in 2007. Diagnosis or reason for use: teeth cleaning. Event abated after use stopped or dose reduced? yes.  Search Alerts/Recalls21

References:

Bibby, B.G: Use of Fluoride in the Prevention of Dental Caries, II. The effects of Sodium Fluoride Applications, Journal of the American Dental Association, 31, 317, Mar. 1, 1944.

Galagan, D.J. and Knutson, J.W.: The Effects of Topically Applied Fluorides on Dental Caries Experience, VI Experiments with Sodium Fluoride and Calcium Chloride….Widely Spaced Applications…Use of Different Solution Concentrations, Public Health Rep., 63, 1215, Sept 17, 1948

Caries Preventive Effect of Fluoride Varnish with Different Fluoride Concentrations, Seppa L, Caries Research 1994; 28; 64 – 67.

Resources

www.elevateoralcare.com