Fluoride: Access, emerging educational challenges pose

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Fluoride: Access, emerging educational challenges pose risks to cavity prevention


Table of Contents

Fluoride: Access, emerging educational challenges pose risks to cavity prevention 3Adults remain at risk for dental caries 11Focus on xerostomia 12Fluoride and root caries 13Answering questions related to fluoride mouth rinses 14Fluoride: A history of prevention worth repeating 15

References 17

A Q/A with Laurie C. Carter, D.D.S., Ph.D. Key questions answered relating to fluoride mouth rinses, xerostomia and patient education 19Biographical sketch 22

References 23

3Fluoride: Access, emerging educational challenges pose risks to cavity prevention


Over the last 70 years, it has been well documented that access to fluoride for the U.S. population has contributed to dramatic declines in the prevalence and severity of tooth decay.1 This e-book was created to help dentists and dental professionals understand challenges and opportunities related to access to fluoride and to aid in facilitating a comprehensive dental homecare regimen to improve oral health.

Some 73 percent of Americans on community water systems have access to fluoridated water, according to the 2018 CDC report on National Water Fluoridation Statistics.2 Water fluoridation prevents at least 25 percent of tooth decay in children and adults throughout their lifespan.1 The majority of large municipalities provide it, but there are exceptions. For example, New Jersey is the 11th most populous state but ranks last in the country for the percentage of its population receiving the benefits of community water fluoridation. Fewer rural than urban water systems are fluoridating.

“Fluoride’s effectiveness in preventing tooth decay extends throughout one’s life, resulting in fewer – and less severe – cavities,” Surgeon General Dr. Vivek H. Murthy included in his 2016 Statement on Community Water Fluoridation.3 “In fact, each generation born over the past 70 years has enjoyed better dental health than the one before it.”

https://www.cdc.gov/fluoridation/statistics/2018stats.htm


https://www.cdc.gov/fluoridation/pdf/sgstatement-03092016.pdf


The difference in tooth decay between optimally fluoridated communities and fluoride deficient communities is significant. However, the difference is lesser now than in the early days of fluoridation. This is partially due to today’s availability of additional sources of fluoride, underscoring the benefits of fluoride for all – from adults to children.

According to a paper published in the June 2019 Journal of Evidence Based Dental Practice, children in families with low income – but not those living in poverty – were less likely than those in other income groups to live in a predominantly fluoridated county.16 Living in a predominantly fluoridated county reduced the magnitude of income inequalities in dental caries of primary teeth for 2- to 10-year-old children but failed to reach statistical significance for permanent teeth of 6- to 17-year-old children.16

“To our knowledge this is the first U.S. study to show evidence that water fluoridation attenuates income-related inequalities in dental caries,” authors said.

Why fluoride

Tooth decay begins when the outer layer of a tooth loses some of its minerals due to acid produced by bacteria in dental plaque breaking down sugars that we eat. Fluoride protects teeth by helping to prevent the loss of these minerals and by restoring them with a fluoride-containing mineral that is more resistant to acid attacks. Fluoride protects teeth by reducing demineralization and enhancing remineralization. Fluoride also works to hinder bacterial activity necessary for the formation of tooth decay.

Studies have shown that fluorides are most effective at preventing, controlling, and reversing early dental caries when various modalities are used in combination with each other. Daily, multiple low exposures to fluoride facilitate the balance between remineralization and demineralization of tooth enamel, reducing caries incidence.4

https://www.sciencedirect.com/science/article/abs/pii/S1532338219301460


They were reporting on a cross-sectional study of participants in the 1999-2004 and 2011 to 2014 cycles of the NHANES. In their robust representative sample of children in the U.S. civilian, non-institutionalized population, 47.7 percent of 2- to 10-year-old-children and 47 percent of 6- to 17-year-old children lived in predominantly fluoridated counties.

“The current findings provide additional support for water fluoridation as a means toward the Healthy People 2020 goals of achieving health equity, eliminating disparities and improving the health of all groups,” authors observed.

Healthy People 2030

Starting with Healthy People 2000, an overarching goal of the Department of Health and Human Services was to provide science-based objectives for improving the health of the public with a focus on disparities. With Healthy People 2020, that goal was expanded to achieve health equity, eliminate disparities, and improve the health of all groups and included an objective to expand the fluoridation of public water supplies.19

Eliminating health disparities, achieving health equity, and attaining health literacy to improve the health and well-being of all is among overarching goals of Healthy People 2030.

Members of the Healthy People 2030 Oral Health (OH) Workgroup have expertise in areas including oral health surveillance, evidence-based dentistry, access to health care services, workforce development and health education. They developed the objectives related to oral health and will track progress toward achieving these objectives throughout the decade. This workgroup has been part of the Healthy People initiative since 1990.


Healthy People 2030 continued

Healthy People 2030 has determined 12 oral health workgroup objectives, including:

� Reduce the proportion of adults with active or untreated tooth decay – OH objective 03.

Summary: “Most adults have tooth decay at some point in their lives, and many don’t get treatment. Making sure more people have access to oral health services and teaching people how to take care of their teeth – for example, by using fluoride mouthwash – can help reduce untreated tooth decay.”

� Reduce the proportion of older adults with untreated root surface decay – OH objective 04

Summary: Older adults are at higher risk of having decay on the roots of their teeth. This can be caused by medication, health conditions, poor diet, or infrequent and ineffective brushing. Making sure more people have access to oral health services and teaching older adults and caregivers how to take care of their teeth – for example, by using fluoride mouthwash – can help reduce untreated root surface decay.”

� Increase the proportion of people whose water systems have the recommended amount of fluoride – OH objective 11.

Summary: “Tooth decay is caused by certain bacteria in the mouth. When a person eats sugar and other refined carbohydrates, these bacteria produce acid that removes minerals from the surface of the tooth. But fluoride can stop or even reverse the tooth decay process – it can help remineralize tooth surfaces and prevent cavities from forming. Adding fluoride to water systems is one of the most effective ways to prevent tooth decay.”


Lack of access to community water fluoridation isn’t the only reason some people are more at risk of experiencing tooth decay than others. Many have access to the cariostatic benefits of tap water but are not drinking it.

One reason could be that bottled water has surpassed all other nonalcoholic beverages to become the most consumed commercial beverage in the United States. It contributes significantly to a person’s total water intake.5

In an effort to investigate and inform the dental profession about the potential anticaries benefits of some bottled waters and to provide information about their possible contributions to fluoride, calcium, magnesium, sodium and potassium intake, researchers published a report in the December 2020 issue of the Journal of the American Dental Association, titled: An investigation into the potential anticaries benefits and contributions to mineral intake of bottled water.5

The findings in this study conclude that the fluoride concentration in 90 of the 92 bottled waters tested in the study were insufficient to contribute to caries prevention.

Fluoride sources

Fluoride is a naturally occurring mineral present at varied concentrations in all water sources including rainwater and the oceans.1 It reaches people in various methods or combinations of methods. Caries protection and appropriateness of fluoride use differs among populations as well as by the fluoride method or combination of fluoride methods used.4

Concentrated fluorides, such as gels, foams, and varnishes, are applied by professionals in the dental practice. Fluoridated water, toothpastes and mouth rinses can contribute to fluoride exposure at home.4

https://jada.ada.org/article/S0002-8177(20)30642-5/fulltext



“Overall, most bottled waters do not contribute to adequate intakes of fluoride, potassium, or sodium or to recommended dietary allowances for calcium and magnesium,” authors reported. Bottled waters included in their study were: purified, spring, sparkling, artesian, mineral, glacial, volcanic, and distilled waters with added minerals.5

A primary concern for consumers choosing bottled water over tap is safety, authors reported. Other reasons include inferior taste and smell of tap water, lifestyle, and convenience.5 Research from the June 2019 issue of JADA, Reasons why low-income people in urban areas do not drink tap water, describe how bottled water consumption has increased while tap water consumption has decreased in low-income communities.13

“For populations with access to community water fluoridation, the replacement of tap with bottled water would lead to decreased fluoride exposure and could result in less anticaries protection for people or populations at high caries risk,” authors commented.5

The common use of at-home water filters or treatment systems was also discussed by the researchers, which, according to the type, can lead to a reduction or complete ineffectiveness of community water fluoridation.5

An estimated one-third of the U.S. population uses an at-home water filter or treatment system to purify their drinking water.5 Some of these systems filter the water before it enters a dwelling. There are also faucet and under-sink filters, countertop, and pitcher systems. Purification approaches include reverse

https://jada.ada.org/article/S0002-8177(18)30837-7/abstract




osmosis, carbon filters, distillation, and ion exchange.5 Water filters with the American Dental Association Seal of Acceptance do not remove fluoride.

Dr. Angeles Martinez Mier, professor and chair of the Department of Cariology, Operative Dentistry and Dental Public Health at the Indiana University School of Dentistry recommends that dental professionals consider the type of water used and, if possible, to consider the mineral content of water consumed by patients during their caries risk assessment, and to adjust fluoride recommendations accordingly.”6

As adults keep teeth at older ages, lower socioeconomic groups are still more at-risk for caries.

“Is tooth decay still a serious problem in the United States?” Authors of Fluoridation Facts1, published by the American Dental Association in 2018, reported, “While cavities are often thought of as a problem for children, adults in the U.S. are keeping their teeth longer (partially due to exposure to fluoridation) and this increased retention of teeth means more adults are at risk for cavities –

Optimal fluoride concentration

Fluoridation is one of the most widely studied public health measures in history.

In 2015, the Department of Health and Human Services announced that the U.S. Public Health Service had made a final recommendation on the fluoride level in drinking water that updated and replaced the 1962 Drinking Water Standards related to community water fluoridation. In this 2015 HHS Guidance, the optimal concentration of fluoride in drinking water of 0.7 mg/L (milligrams per liter) was defined as “the concentration that provides the best balance of protection from dental caries while limiting the risk of dental fluorosis.”1,14

http://www.ada.org/~/media/ADA/Files/Fluoridation_Facts.pdf?la=en


especially decay of exposed root surfaces. Tooth root surfaces are covered with cementum (a softer surface than the enamel) and so are susceptible to decay.”

In the January 2019 issue of JADA about tooth loss over time in older adults,15 research showed that complete tooth loss has decreased by more than 75 percent for those aged 64 through 74 years over the past five decades, with the improvements most significant among those who are not experiencing poverty.15 “The practice implications of an aging population retaining more teeth is that older adults may need more regular health care and prevention services to address concerns such as root caries and periodontal disease,” study authors observed.

Fluoride mouth rinses, caries prevention and age-appropriate use

Mouth rinsing programs have been used for many years as a community-based caries prevention strategy for children ages 6 years and older. It’s widely accepted that by age 6, most children can rinse and spit with little to no ingestion, making a rinse a good method for topical fluoride.

Fluoride rinses are not recommended for children under the age of 6 because some young children might swallow the rinse rather than spit it out.

Fluoride mouth rinses work in the same way as other topical fluorides by enhancing fluoride concentrations in saliva, plaque and enamel. Laboratory and epidemiologic evidence indicate the effect depends on regular fluoride availability.

Typically, fluoride rinses containing a concentration of 0.2 percent sodium fluoride (920 ppm fluoride) are indicated for weekly supervised school rinsing programs.4

Over-the-counter solutions of .05 percent sodium fluoride (230 ppm fluoride) for daily rinsing are available for use by people older than 6 years of age.17



While the presence of untreated caries for children, particularly low-income children, fell between 1999 and 2014 and again in 2015-2016, the rates for all seniors and adults were stable, according to an ADA Health Policy Institute analyses of NHANES data in a report titled Untreated Caries Rates Falling Among Low-Income Children.18

Adults remain at risk for dental caries

Research shows that 92 percent of adults ages 20 to 64 have had dental caries in their permanent teeth. The percentage of adults with caries, missing or filled permanent teeth, increases from about 86 percent among those aged 20 to 34 to 94 percent among those aged 35 to 49, to nearly 96 percent among those 50 to 64.7

Once caries are restored, the tooth is still at risk for recurrent decay. These open margins can harbor bacteria that start the cavity process over again or leak, allowing bacteria to enter the tooth below the existing filling.1

The ADA Fluoridation Facts1 report cites research projecting that as Baby Boomers age, their root decay experience could increase to the point where older adults experience similar or higher levels of new cavities than do school children. Root caries can lead to pain, tooth loss, and affect the quality of life. Older age, poorer oral hygiene, xerostomia, lower socioeconomic status, and tobacco use are associated with higher risk.

https://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIgraphic_0617_2.pdf?la=en



Focus on xerostomia

Xerostomia, or dry mouth, is another common problem for adults. Many medications to control chronic conditions reduce the flow of saliva. It’s a common condition that can affect quality of life among people of all ages, including younger adults and individuals who have undergone head and neck radiation therapy, those with conditions including Sjögren’s syndrome, diabetes mellitus and Parkinson’s disease. As people are living longer, the incidence of polypharmacy compounds the problem. Xerostomia affects 30 percent of patients older than 65 years and up to 40 percent of patients older than 80 years.10

A 2015 paper of the ADA Council on Scientific Affairs titled Managing xerostomia and salivary gland hypofunction reported that chronic xerostomia significantly increases the risk of dental caries, demineralization, tooth sensitivity, candidiasis and other oral diseases that may negatively affect quality of life.11 It suggests that a systematic approach to xerostomia management can facilitate interdisciplinary patient care, including collaboration with physicians regarding systemic conditions and medication usage.

“Comprehensive management of xerostomia and hyposalivation should emphasize patient education and lifestyle modifications. It also should focus on various palliative and preventive measures, including pharmacological treatment with salivary stimulants, topical fluoride interventions, and the use of sugar-free chewing gum to relieve dry-mouth symptoms and improve the patient’s quality of life.”

https://www.ada.org/~/media/ADA/Science%20and%20Research/Files/CSA_Managing_Xerostomia.pdf?la=en

https://www.ada.org/~/media/ADA/Science%20and%20Research/Files/CSA_Managing_Xerostomia.pdf?la=en


Fluoride and root caries

Researchers interested in primary prevention methods for dental root caries conducted a systematic review with network meta-analysis on the effectiveness of professionally and self-applied topical fluorides and published their findings in the Journal of Dental Research in 2020.8

Aiming to summarize and synthesize the best clinical evidence, they used network meta-analysis – allowing them to compare more than two treatments by connecting evidence from different clinical trials that assessed the same or similar treatments with similar objectives. Results showed:

� Both professionally and self-applied fluorides are effective in preventing dental root caries.

� Fluoride mouth rinse and fluoride toothpaste, used alone or in combination, reduced root caries after one year.8

Among reviewed self-applied topical fluoride methods, the three that performed best in preventing root caries for one year were as follows: 0.2 percent NaF (sodium fluoride) mouth rinse was most effective; followed by the combined use of 1100 ppm and 1500 ppm fluoride toothpaste and 0.05 percent NaF mouth rinse; followed by 1100 ppm to 1500 ppm fluoride toothpaste used alone.8

https://pubmed.ncbi.nlm.nih.gov/32142400/


Answering questions related to fluoride mouth rinses

Dental professionals advising a home fluoride regimen should have a conversation with the patient about the proper use of fluoride products. They should demonstrate the application of the recommended amount of fluoridated toothpaste on the toothbrush and tell patients how long to brush (2 minutes), twice a day (morning and evening).9 Dental professionals should also recommend that a fluoride rinse be used after tooth brushing. One benefit of recommending a 0.05% NaF rinse is that patients only have to rinse

one time a day, which may aid in patient compliance. It is important to remind patients not to swallow the rinse or to rinse with water following the application. Patients should not eat or drink for 30 minutes after using a fluoride mouth rinse.9

Fluoride retention: clinical trial

Scientists at the University of Michigan are currently conducting a clinical trial in two experimental phases to assess fluoride retention in the mouths of older adults. Patients with a range of saliva flows – from normal to dry mouth will rinse with a fluoride rinse only (used at over-the-counter concentrations), or a fluoride rinse preceded by a calcium rinse. The concentration of fluoride and calcium in the saliva and dental plaque residues will be determined up to two hours after the rinse(s) to test the effect of the approach to optimize fluoride retention in the mouth of patients with dry mouth.

Participants with normal to dry mouth will be treated, in a crossover design, with two interventions: a 0.05 percent (226 parts per million of fluoride) fluoride mouth rinse alone, or a fluoride mouth rinse preceded by a calcium mouth rinse.12


Fluoride: A history of prevention worth repeating

For those who lived before community water fluoridation, the days have never grown distant enough to live without the consequences.

Most people ended up with a mouthful of extractions. Tooth removal solved immediate problems but created new ones. Stand-ins for missing teeth – dentures and bridges – created other lifelong problems.

As society began to have longer life-expectancy, dental caries risk remained. Those able and inclined to pursue fillings kept their teeth longer. However, little more than one quarter of the population visited a dentist at all.20

According to a 1940 paper published by the American Dental Association, among people who visited the dentist, the average time between visits was 2.5 years. That meant that carious tooth surfaces in children were developing five times faster than they were filled. Accumulating decay struck 1.32 tooth surfaces each year. By the time a person was 25-years old, 18 teeth were likely affected.20

Meanwhile, dental researchers were finding that residents living in regions with high levels of naturally occurring fluoride in the drinking water had mottled dental enamel (now called fluorosis), but also resistance to dental caries.

Intensive research brought to light that where domestic water contained 1.2 ppm (parts per million) of fluoride, residents had a low prevalence of tooth decay and did not have mottled enamel. It was also observed that fluoride levels of up to 1.0 ppm in drinking water caused mild dental fluorosis, also described as “almost imperceptible,” in only a small percentage of people.


Talk about a critical discovery that came not a moment too soon. The 1940s followed up with community-wide comparison studies evaluating the controlled addition of sodium fluoride water supplies to fluoride-deficient water supplies. Outcomes firmly established water fluoridation as a practical, safe, and effective public health measure to prevent tooth decay.

Ongoing reviews of fluoride in drinking water through the years led to the first Surgeon General Report on Oral Health in 2000 calling out community water fluoridation as the most cost-effective, practical and safe means for reducing and controlling the occurrence of tooth decay. “Water fluoridation is a powerful strategy in efforts to eliminate health disparities among populations,” Dr. David Satcher noted in the report. He predicted (correctly) that the baby boomer generation would be the first in which the majority of people would maintain natural teeth over the course of their entire lifetime.


References

1. ADA. Fluoridation Facts. 2018. Available at: http://www.ada.org/~/media/ADA/Files/Fluoridation_Facts.pdf?la=en. Accessed on March 17, 2021.

2. CDC. Water Fluoridation Reporting System. 2018. Accessed on 3/16/2021: https://www.cdc.gov/fluoridation/statistics/2018stats.htm

3. V. Murthy. Statement on Community Water Fluoridation. Department of Health and Human Services, 2016. Accessed on 3/16/2021: https://www.cdc.gov/fluoridation/pdf/sgstatement-03092016.pdf

4. Association of State and Territorial Dental Directors (ASTDD). March 1, 2011. School-Based Fluoride Mouthrinse Programs Policy Statement.

5. L. Almejrad, J. Levon, A. Soto-Rojas, Q. Tang, F. Lippert. JADA. An investigation into the potential anticaries benefits and contributions to mineral intake of bottled water. 2020;151(12):924-934.e10. Available at: https://jada.ada.org/article/S0002-8177(20)30642-5/abstract. Accessed on 3/16/2021.

6. E. Martinez Mier. Practice Update. Most bottled waters do not contain cariostatic concentrations of fluoride. 2021. Available at: https://www.practiceupdate.com/content/most-bottled-waters-do-not-containcariostatic-concentrations-of-fluoride/110774. Accessed on 4/5/2021.

7. National Institute of Dental and Craniofacial Research. Dental caries (tooth decay) in adults age 20-64. Available at: https://www.nidcr.nih.gov/research/data-statistics/dental-caries/adults. Accessed on 4/10/2021.

8. J. Zhang, D. Sardana, K. Li, K. Leung, E. Lo. J Dent Res. Topical Fluoride to Prevent Root Caries: Systematic Review with Network Meta-analysis. 2020 May;99(5):506-513. Available at: https://pubmed.ncbi.nlm.nih.gov/32142400/. Accessed on March 17, 2021.

9. Interview with Laurie C. Carter, D.D.S., Ph.D. (2021, March).

10. American Dental Association (2021, February). Oral Health Topics. https://www.ada.org/en/member-center/oral-health-topics/xerostomia

11. ADA Council on Scientific Affairs. Feb. 2015. Managing xerostomia and salivary gland hypofunction. Available at: https://www.ada.org/~/media/ADA/Science%20and%20Research/Files/CSA_Managing_Xerostomia.pdf?la=en March. Accessed on March 17, 2021.

12. National Institutes of Health. U.S. National Library of Medicine. Fluoride Retention in the Mouth of Older Adults. Available at: https://clinicaltrials.gov/ct2/show/NCT04239872. Accessed on March 17, 2021.

13. L. Family, G. Zheng, M. Cabezas, J. Cloud, S. Hsu, E. Rubin, L. Smith, T. Kuo. JADA. Reasons why low-income people in urban areas do not drink tap water. 2019; 150(6):503-513. Available at: https://jada.ada.org/article/S0002-8177(18)30837-7/abstract. Accessed on March 17, 2021.

14. U.S. Department of Health and Human Services. Federal Register. Public Health Service Recommendation for Fluoride Concentration in Drinking Water for Prevention of Dental Caries. May 1, 2015. Available at: https://www.federalregister.gov/documents/2015/05/01/2015-10201/public-health-service-recommendation-for-fluoride-concentration-in-drinking-water-for-prevention-of. Accessed on March 17, 2021.





https://www.cdc.gov/fluoridation/pdf/sgstatement-03092016.pdf

https://jada.ada.org/article/S0002-8177(20)30642-5/abstract.%20Accessed%20on%203/16/2021

https://jada.ada.org/article/S0002-8177(20)30642-5/abstract.%20Accessed%20on%203/16/2021

https://www.practiceupdate.com/content/most-bottled-waters-do-not-contain-cariostatic-concentrations-of-fluoride/110774

https://www.practiceupdate.com/content/most-bottled-waters-do-not-contain-cariostatic-concentrations-of-fluoride/110774

https://www.nidcr.nih.gov/research/data-statistics/dental-caries/adults



https://www.ada.org/en/member-center/oral-health-topics/xerostomia

https://www.ada.org/en/member-center/oral-health-topics/xerostomia

https://clinicaltrials.gov/ct2/show/NCT04239872



https://www.federalregister.gov/documents/2015/05/01/2015-10201/public-health-service-recommendation-for-fluoride-concentration-in-drinking-water-for-prevention-of

https://www.federalregister.gov/documents/2015/05/01/2015-10201/public-health-service-recommendation-for-fluoride-concentration-in-drinking-water-for-prevention-of


15. B. Dye, D. Weatherspoon, G. Lopez Mitnik. JADA. Tooth loss among older adults according to poverty status in the United States from 1999 through 2004 and 2009 through 2014. 2019; 150(1):9-23.E3. Available at: https://jada.ada.org/article/S0002-8177(18)30644-5/abstract. Accessed on March 17, 2021.

16. H. Pollick. Community water fluoridation benefits US children from poor families more than those from more affluent families. Journal of Evidence-Based Dental Practice. 2019. Subscription access: https://www.sciencedirect.com/science/article/abs/pii/S1532338219301460

17. R. Weyant, et al. JADA. Topical fluoride for caries prevention. Nov. 2013; 144(11):1279-1291. Available at: https://jada.ada.org/article/S0002-8177%2814%2960659-0/fulltext. Accessed on April 15, 2021.

18. ADA Health Policy Institute. Untreated caries rates falling among low-income children. Available at: https://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIgraphic_0617_2.pdf?la=en. Accessed on March 17, 2021.

19. Department of Health and Human Services (2010, December). Healthy People 2020. https://www.cdc.gov/nchs/healthy_people/hp2020.htm

20. J. Fulton. A National Dental Care Program: Presentation of the Dental Problem. JADA. 1945; 32(10): 1244. Available at: https://www.sciencedirect.com/sdfe/pdf/download/eid/1-s2.0-S0002817745190022/first-page-pdf. Accessed on 4/10/2021.




https://jada.ada.org/article/S0002-8177%2814%2960659-0/fulltext



https://www.cdc.gov/nchs/healthy_people/hp2020.htm

https://www.cdc.gov/nchs/healthy_people/hp2020.htm

https://www.sciencedirect.com/sdfe/pdf/download/eid/1-s2.0-S0002817745190022/first-page-pdf

https://www.sciencedirect.com/sdfe/pdf/download/eid/1-s2.0-S0002817745190022/first-page-pdf


A Q/A with Laurie C. Carter, D.D.S., Ph.D. Key questions answered relating to fluoride mouth rinses, xerostomia and patient education

Q: Do you think that fluoride mouth rinses at recommended doses that have the ADA Seal should have a place in both dentist and consumer toolkits for caries prevention in adults?

Dr. Carter: Absolutely. A study by Zhang and colleagues in The Journal of Dental Research in 2020 demonstrated that among the reviewed self-applied topical fluoride methods, daily use of a 0.2% sodium fluoride mouth rinse (prescription) is most effective in reducing root caries, followed by 1100 ppm to 1500 ppm fluoride toothpaste plus 0.05% sodium fluoride mouth rinse (available over-the-counter), and 1100 ppm to 1500 ppm fluoride toothpaste compared with non-fluoridated controls after one year of use.1

Clinical recommendations from a scientific panel, convened by the American Dental Association Council on Scientific Affairs, about fluoride were presented in a 2013 article in JADA (Weyant, et al.). Recommendations included 2.26% F- varnish or 1.23% APF gel, prescription-strength home-use 0.05% F- gel/paste or 0.09% F- rinse for patients 6 years or older.2

Q: As adults are living longer they’re also on more medications that can cause dry mouth and higher caries incidence. Using a .02 percent fluoride mouth rinse specifically made for xerostomia is often recommended. Do you think that can be a good idea for some older adults at risk?




Dr. Carter: I certainly do. Yes, many medications can induce xerostomia, and as patients are living longer, the incidence of polypharmacy compounds this problem. There are other populations at risk for xerostomia as well – patients with Sjögren’s syndrome and individuals who have undergone head and neck radiation therapy which may have damaged the salivary glands come to mind. In addition, besides xerostomia, dentists should also consider older adults who may have difficulty performing oral hygiene due to hand deformities caused by rheumatoid arthritis or Dupuytren’s contractures, for instance, who would also benefit greatly from the cariostatic benefits of topical fluoride rinses. Also, one might consider adding a capful of fluoridated mouth rinse to the water flosser reservoir.

Q: If an adult patient drinks optimally fluoridated water but might benefit from additional fluoride at home through a rinse or toothpaste, what is the best way to dispel his or her concerns about adults potentially using too much fluoride?

Dr. Carter: The dentist needs to apply professional judgment when assessing each patient’s caries risk and take into account other personal factors when determining how to help the patient manage home care, balancing potential benefit with potential harm. If the dentist advises a home fluoride regimen, he or she needs to have a conversation with the patient about the proper use of the product – demonstrate the application of the recommended amount of fluoridated toothpaste to the toothbrush and tell patients how long to brush (2 minutes) twice a day, morning and evening. Fluoride rinse should be used after toothbrushing (for those ages 6 and over). Demonstrate where the fill line is on the cap of the fluoride mouth rinse bottle and tell patients how long to swish the rinse (1 minute). For some fluoride mouth rinses, manufacturers recommend use twice a day, however OTC 0.05% sodium fluoride formulas require only rinsing once a day, at bedtime, which may help in patient compliance. Explain to patients to follow the approved label and


not to exceed those recommended amounts. It’s important to emphasize that patients should expectorate (spit out) these products and not swallow them. They should not rinse with water after using the fluoride rinse and should wait 30 minutes before eating. Explain that the products have been formulated to be both safe and efficacious if used as directed. The ADA Seal of Acceptance on the product packaging means the manufacturer conducted rigorous scientific study of the product and the ADA Council on Scientific Affairs has reviewed the data carefully before determining to grant the product the ADA Seal. Potential harm from topical fluorides include nausea and vomiting. Patients with Parkinson’s disease or other mechanical deglutition (swallowing) disorders would probably be better served by in-office professional application of fluoride products.

Q: Can you talk a little bit more about good methods for counselling patients so they will set their own goals when it comes to taking steps for better oral self-care between dental visits?

Dr. Carter: One critical talking point would be the importance of drinking tap water in fluoridated communities. Talk to patients about the Almejrad et al. study (An investigation into the potential anticaries benefits and contributions to mineral intake of bottled water, December 2020 issue of JADA.) which found that only 2 of 92 bottled water brands tested contained > 0.7 ppm fluoride, the optimal concentration put in tap water.3 Most patients simply are unaware that this is the case. Have a discussion with your patients about the fact that most water filters, whether point-of-entry, faucet, under-sink filters or pitcher systems remove some to all of the fluoride out of the tap water. Suggest that if they want to filter their tap water, to only use water filters that do not remove fluoride, such as those with the ADA Seal of Approval. Dentists should be cognizant of the fluoride levels in their community water system and know where their patients can have their water tested for it.




Q: Are there any strategies you use or recommend using to address confusion about benefits of fluoride for both adults and children?

Dr. Carter: Educate patients at every opportunity, at every dental visit, both with the dentist and the dental hygienist. General and pediatric dentists can volunteer to speak to school groups and parent-teacher associations about these topics. Get involved with efforts to produce PSAs (public service announcements) in your area. Go where the patients go – harness the power of social media to get out these messages. Have Facebook and Instagram thumbnail links on your practice webpage. Google owns YouTube – get a YouTube channel and post short videos on Oral Health Tips, including topics on community water fluoridation, the importance of drinking tap water, cautions about water filters, use of topical fluoride gels and rinses.

Biographical sketch

Laurie C. Carter received a D.D.S. degree and Certificate of Proficiency in Oral Pathology from the SUNY at Buffalo School of Dental Medicine and M.A. and Ph.D. degrees in Experimental Pathology from the SUNYAB School of Medicine and Biomedical Sciences. She is a Fellow of the American Academy of Oral and Maxillofacial Pathology and the American Academy of Oral and Maxillofacial Radiology (AAOMR). She is a Past-President of AAOMR and served terms on the ADA Council on Scientific Affairs and ADA Commission for Continuing Education Provider Recognition. She was Consulting Editor for JADA Specialty Scan – Radiology for 7 years. Dr. Carter is Professor Emeritus of Oral Diagnostic Sciences at Virginia Commonwealth University School of Dentistry and is an Editorial Contributor for PracticeUpdate Clinical Dentistry, a collaboration of Elsevier and the American Dental Association.


References

1. J. Zhang, D. Sardana, K. Li, K. Leung, E. Lo. J Dent Res. Topical Fluoride to Prevent Root Caries: Systematic Review with Network Meta-analysis. 2020 May;99(5):506-513. Available at: https://pubmed.ncbi.nlm.nih.gov/32142400/. Accessed on March 17, 2021.

2. R. Weyant, et al. JADA. Topical fluoride for caries prevention. Nov. 2013; 144(11):1279-1291. Available at: https://jada.ada.org/article/S0002-8177%2814%2960659-0/fulltext. Accessed on April 15, 2021.

3. L. Almejrad, J. Levon, A. Soto-Rojas, Q. Tang, F. Lippert. JADA. An investigation into the potential anticaries benefits and contributions to mineral intake of bottled water. 2020;151(12):924-934.e10. Available at: https://jada.ada.org/article/S0002-8177(20)30642-5/abstract. Accessed on 3/16/2021

Explore Fluoride Resources Learn More

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Visit ACTOralCarePro.com for more information and free coupons, samples, and patient materials.

Explore fluoride resources at the DPS Product Learning Center, an ACT-sponsored digital resource about fluoride and its products.

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https://pages.ada.org/fluoride

https://actoralcareprofessional.com/

http://ACTOralCarePro.com

Documents

Fluoride: Access, emerging educational challenges pose