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How Fluoride Varnish Combats Early Childhood
Caries
Daniel Ravel, DDSFayetteville, NC
Early Childhood Caries (ECC)• Caries in primary dentition under age
5
• Affects 35% of 3 year olds
• Bacteria are the causative agent
• Destroys tooth structure, often rapidly
• Usually affects maxillary incisors first
• Potentially severe consequences could include pain, tooth loss, pulpitis, pulp necrosis and dental abscess
8
Oral bacteria (mutans strep) break down dietary sugars into acids which break down the tooth
ECC Etiology Triad
CariesCariesSugars
Bacteria Teeth
9
ECC Risk Assessment
10
Why is Risk Assessment Important?
• 80% of ECC occurs in 20% of children
• Risk status determines:– Age of first dental visit– Use of fluoride– Depth of nutritional and hygiene
counseling– Begin before or with first tooth (4-6
months)
11
Assessing Caries Risk
High:Multiple risk factors and:
• Plaque on teeth• Presence of white
spots or cavities• No systemic fluoride
exposure
Moderate: One of following risk factors:
• Lower SES• Poor access to health care• Family members have cavities
– particularly mother• Diet – drinks or eats sugar
containing foods two or more times between meals
• Diet - sleeping with bottle or at breast
• Special health care needs• Developmental defects (often
in premature babies)
Low
12
ECC Recognition
Photo: Joanna Douglass BDS DDS
Knee to Knee Oral Exam
1. Child is held facing care giver in a straddle position
2. Child leans back onto examiner while caregiver holds child’s hands
3. Provider performs exam while caregiver holds child’s hands and legs
Photos: Mark Deutchman MD
14
Healthy Teeth
Photos: Joanna Douglass BDS DDS
15
Early Stage of ECC: White to Brown Spots
Photos: Joanna Douglass BDS DDS
16
Early Aggressive ECC
Photos: Joanna Douglass BDS DDS
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Fluoride
20
Ongoing Balance
No caries
Caries
Protective FactorsSalivary flow
Fluoride
Pathologic Factorsmutans strep
CarbohydratesReduced salivary flow
21
Mechanism of Action
• Topical (greater effect)– Inhibits demineralization – Promotes remineralization– Produces anti-bacterial activity
• Systemic (lesser effect)– Reduces enamel solubility by
incorporation into its structure
23
Sources of Fluoride
Systemic Water fluoridation Fluoride supplements
Topical Fluoride toothpastes Gels, foams,
mouthwashes Fluoride varnish
24
SystemicFluoride
TopicalFluoride
LowRisk
ModRisk
HighRisk
Fluoridated water
Fluoride tablets/drops
Toothpaste
Fluoride Varnish
Yes Yes Yes
Yes Yes
Yes Yes
Yes YesNo
?
*
* After age 2 all children should use fluoridated toothpaste
Fluoride Use Recommendations
25
Evidence of Benefit for Fluoride • General Population
(USPSTF 1989, 1996)– Fluoridated toothpaste (I, A)
• High Risk Populations (MMWR 2001)
– Water supplementation reduces caries by 30%– Fluoride supplement if water <.3ppm (6-12 yr-olds)(I,A)
– Topical fluoride gels (I, A)
– Fluoride varnishes on permanent teeth (I, A)
– Fluoride varnish on high risk infants (I, A)
26
Fluoride Varnish
27
Benefits• Can be quickly and easily applied• Application does not have to be
done by a physician• Dry tooth surface facilitates fluoride
uptake• Sets on contact with moisture• Taste is tolerable• Can reverse early decay (“white
spots”) and slow enamel destruction in active ECC
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Indications• Moderate and high risk
children without caries• Children with “white spots”• Children with caries• Generally applied twice per
year beginning when teeth erupt
• Varnish is not a replacement for appropriate diet, regular brushing, indicated systemic fluoride supplements, or routine dental care!
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Available Preparations0.25ml unidose 5% NaF (2.26% F)
CavityShieldOMNII
$1.00 per dose
DuraflorMedicom
$1.00 per dose
Enamel Pro VarnishPrimier
$1.60 per dose
31
Flor-OpalUltradent
$2.00 per dose
All SolutionsDentsply
$1.60 per dose
Follow-up• After application of topical fluoride:
Offer caries preventive advice Assess need for fluoride supplements Plan next visit to the medical home Refer to dental home (if needed)
• If a child has active caries Intensive counseling and preventive
measures Urgent definitive dental referral
33
Hygiene Advice: Tooth Brushing• Start when teeth erupt• Brush twice daily • Bedtime most critical • Caregiver brushes until age 6• Child can stand in front of
caregiver or lie face up in lap• Spit after brushing, not rinse• Use rice size or smear of
fluoridated toothpaste• Lift lip; brush behind teethPhotos: Joanna Douglass BDS DDS
23
High Risk Eating Pattern AdviceEating Pattern
Frequent snacking – 2 +times between meals
Sticky, retentive snacks, slow dissolving carbohydrates
Sequence of eating & time
Examples
Candy, sippy cup of juice or soft drink, graham crackers, cookies
Raisins, dried fruit, fruit rolls, bananas, caramels, jelly beans, peanut butter/jelly sandwich
Chewable vitamins at end of meal, food or drink after brushing and before bed
24
Healthy Snacks AdviceHappy FoodsFruitVeggiesCheeseCrackersPretzelsPopcornNutsPeanut ButterCheese CrackersSugar Free GumMilkWater100% pure fruit juice (only
4 oz per day)
Sad FoodsFruit Roll-upsFruit by the FootFruit WrinklesGummy BearsCookiesCupcakesSugared CerealsGranola BarsPop TartsSoda, Gatorade, Ice Tea
DonutsSugar drinks
25
Fluoride Supplementation Advice
26
Dosages are in milligrams F/day
6 mos – 3 yrs 0.25 mg None None
3 yrs – 6 yrs 0.50 mg 0.25 mg None
> 6 years 1.00 mg 0.50 mg None
< 0.3 ppm 0.3 – 0.6 > 0.6 ppmppm
Water Fluoride ConcentrationChild’s Age
Age 1 Dental Visit Referral• The American Academy of
Pediatric Dentistry recommends a dental evaluation by the 1st birthday
• The American Academy of Pediatrics recommends establishment of a dental home by the 1st birthday for children at high risk
• If limited dental access, clinician assumes responsibility for screening and guidance
27
Applying Fluoride Varnish
34
Applying Fluoride Varnish: Step 1
• Assemble the required supplies:– Varnish– Toothbrush– Gauze
36
Applying Fluoride Varnish: Step 2Visually inspect all the child’s teeth and document any white spots and/or cavities for future follow-up
Hints• Use the knee-to-knee
exam• Show the toothbrush to
prompt opening of the mouth
Photos: ICOHP
37
Applying Fluoride Varnish: Step 3
Use a 4x4 gauze pad to dry the child’s teeth and remove gross plaque
Photo: ICOHP
38
Applying Fluoride Varnish: Step 4
Apply varnish to all the surfaces of the dry teeth
Note: The varnish will not adhere if it is applied to wet teeth, but saliva contamination after the application is fine
Photos: ICOHP
39
Applying Fluoride Varnish: Step 5
Tell the caregiver:• The child’s teeth will be
discolored for 24-48 hours
• Do not brush the child’s teeth for 12-24 hours
• Avoid giving the child hot, sticky or hard foods for 24 hours
40
Photo: ICOHP
Fluorosis and the Safety of Fluoride Varnish
41
Fluorosis• Discoloration of teeth due to chronic
excessive exposure to Fluoride while teeth are developing
• Risk greatest at intake of greater than 0.06 mg/kg/day
• Prevalence of Fluorosis: 0.2% - 27%
Photos: John McDowell DDS, Joanna M. Douglass BDS DDS
42
Reducing the Risk of Fluorosis• Determine the fluoride content of the
child’s drinking water• Consult with the child’s dentist to avoid
duplicating fluoride prescriptions• Follow current dosage schedules for
systemic fluoride supplementation• Tell the child’s caregiver to place only a
rice-grain size dab of fluoridated toothpaste on the child’s toothbrush
• Keep fluoride containing products out of the reach of small children
43
Safety of Fluoride Varnish
• 5% NaF varnish = 26,000 ppm fluoride• A 0.5 milliliter application of fluoride
varnish contains < 6 milligrams of fluoride• Negligible fluoride levels are detected in
blood and urine • Fluoride varnish is as safe as other topical
fluoride applications via toothpastes, rinses, and gels
44
Take Home Messages• ECC is a significant health problem for
children• As a medical clinician, you can play a key role
in preventing ECC• Fluoride varnish is one part of a
comprehensive approach to a child’s oral health
• Fluoride varnish is safe and effective • You can apply fluoride varnish to a child’s
teeth as a part of a routine visit• You can minimize the risk of fluorosis by
educating the child’s caregivers
46