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Prevention. Part 7: Professionally applied topical fluorides for caries

prevention

Article  in  British Dental Journal · October 2003

DOI: 10.1038/sj.bdj.4810527 · Source: PubMed

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PRACTICE

IN BRIEF
●

●
Topical fluoride treatments are safe and effective but should be applied only to patients with
decayed smooth surfaces or those at high risk of caries.
Both APF gel and fluoride varnish are effective and can be recommended for caries
prevention in permanent teeth. To maximize fluoride uptake, gels should be applied for
4 minutes.
The frequency of fluoride application depends on individual risk, but should be at least
biannual when indicated.
Cleaning or prophylaxis is not necessary prior to the application of topical fluorides.
7
VERIFIABLE
CPD PAPER
Prevention. Part 7: Professionally applied
topical fluorides for caries prevention
R. Hawkins1, D. Locker2 and J. Noble3; Series Editor E. J. Kay4

This paper reviews the use of professionally applied topical fluorides (PATF) in caries prevention. PATFs are indicated for
children and adults with one or more decayed smooth surfaces and/or those who are at high caries risk. Frequency of
administration depends on the patient's caries risk, and is usually every 6 months. The effectiveness of fluoride varnish and
gel applications has been well established in caries prevention trials involving permanent teeth. Although both types are
effective, varnish may be preferred because it is easier to apply, reduces the risk of fluoride over-ingestion, and has greater
patient acceptance. Fluoride foams are similar products to gels, but have not been tested clinically. The use of in-office
two-part rinses is not recommended because they have not been proven effective. A cleaning, or prophylaxis, is not necessary
before the application of topical fluoride for caries prevention. In conclusion, when used appropriately, PATFs are a safe,
effective means of reducing caries risk among high-risk populations.

Caries prevalence among children in western Type 1: Systematic review of two or more
PREVENTION countries has fallen dramatically over the past clinical trials
1. Smoking cessation three decades.1 Not all children, however, have Type 2: At least one randomized controlled trial
advice experienced the same degree of caries risk reduc- Type 3: Non-randomized intervention studies
2. Dietary advice tion, and dental decay remains a significant Type 4: Observational studies
3. Prevention of tooth wear problem for a substantial minority of high-risk Type 5: Other designs, traditional literature
4. Toothbrushing advice children. The decline in caries prevalence has reviews, expert opinion.
5. Patients requiring also not been uniform across tooth surfaces. On
osseointegrated oral a percentage reduction basis, occlusal lesions WHICH PATIENTS SHOULD RECEIVE PATF?
implant treatment have declined less than lesions on other tooth PATF should not be applied on a routine basis in
6. Older dentate patient surfaces, and make up a higher proportion of the dental practices. A patient's susceptibility to
7. Professionally applied burden of dental caries.2 caries must first be determined and, based on
topical fluorides for The use of professionally applied topical fluo- this information an appropriate preventive care
caries prevention ride (PATF) is one means of preventing caries plan should be designed for each individual. The
8. Pit and fissure sealants in that is frequently used in private practice and surfaces at risk for decay must also be consid-
preventing caries in the public health settings. In terms of the relative ered because PATF is more effective against
permanent dentition of reduction in decayed and filled surfaces, PATF is smooth surface caries than against pit and fis-
children more effective against smooth surface caries sure caries.
than occlusal caries.3 Given the present charac- Topical fluoride applications are indicated for
1Research Associate, 2Director, 3Research
teristics of dental caries, the appropriate use of patients with active smooth surface caries and
Assistant, Faculty of Dentistry, University
of Toronto, Ontario, Canada;
PATF in developed countries must be examined. those patients in high caries risk groups (Table 1).
4Professor of Dental Health Services Dental personnel have a wide choice of dif- This includes special patient groups, such as
Research, University of Manchester Dental ferent PATF agents, vehicles, and regimens; and those undergoing orthodontic treatment. In
Hospital and School, Higher Cambridge should be aware of the supporting evidence high-risk groups, evidence indicates an anti-
Street, Manchester M15 6FH
*Correspondence to: Dr Robert Hawkins, upon which to base their decisions. To gain a caries effect over a 2-year period,4 but PATF
Community Dental Health Services Research better understanding of the use of PATF, the fol- application does not make a significant differ-
Unit, Faculty of Dentistry, University of lowing issues are reviewed: indications for use; ence in low-to-moderate risk children who also
Toronto, Room 521, 124 Edward Street,
Toronto, Ontario, Canada M5G 1G6
caries prevention effectiveness and clinical receive water fluoridation and dental sealants.5,6
E-mail: [email protected] application of different types of PATF; fluoride From a cost-effectiveness perspective, patients
ingestion and toxicity; and whether a cleaning is with low caries risk who reside in optimally
Refereed Paper necessary prior to topical fluoride application. fluoridated areas are unlikely to benefit from
doi:10.1038/sj.bdj.4810527
© British Dental Journal 2003; 195: The strength of the evidence was classified using PATF therapy. The number of children that must
313–317 the following typology: be treated to prevent one decayed surface is esti-

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PRACTICE

Table 1 Indications for use of professionally applied topical fluorides clusions of the meta-analysis. In a high-risk
community, children who received at least two
• Patients who are at high risk for caries on smooth tooth surfaces varnish applications per year showed a 37%
• Patients who are at high risk for caries on root surfaces reduction in mean caries increment for a 4-year
• Special patient groups, such as: period compared with a control group.12 Simi-
Orthodontic patients larly, the effectiveness of fluoride varnish was
Patients undergoing head and neck irradiation supported in 24- and 48-month comparison
Patients with decreased salivary flow studies of varnish and dental sealants.13,14 In the
• Children whose permanent molars should, but cannot, be sealed 24-month report, compared with the control
• Not recommended for patients with low caries risk who reside in group, the use of fluoride varnish resulted in a
communities with optimal fluoridation 66% reduction in DMFS on non-fissured sur-
faces and a 38% reduction on fissured surfaces.
However, in both reports, dental sealants were
mated at 18 if caries incidence is low, but only found to have superior performance for the pre-
3 for groups with high caries incidence.7 vention of decay.
A possible indication for the use of PATF is The only direct comparison of the effective-
adults with exposed root surfaces. The problem ness of fluoride varnish and gel, in a developed
of root caries is likely to increase due to popula- country, showed no statistically significant dif-
tion aging and the increased retention of teeth. ferences between the treatment groups (NaF var-
However, no clinical studies have yet examined nish and APF gel).15 In this 3-year RCT study
the potential benefits of this intervention. involving 12–13-year-olds, the mean total
DMFS increments were 3.1 and 3.6 for the var-
FLUORIDE VARNISH nish and gel groups, respectively. The findings
Since their introduction in the 1960s, fluoride suggested varnish was as effective as gel for
varnishes have become the most widely used caries prevention.
Biannual application PATF in Europe.8,9 The most common types of For the primary dentition, the evidence is lim-
of fluoride varnish NaF varnish are Duraphat (2.2% F) and Fluor ited and only two randomized controlled trials
can result in a Protector (0.1% F). The advantage of varnish is have been conducted. Several studies of fluoride
reduction of 38% its ability to adhere to tooth surfaces, which pro- varnish have reported prevented fraction per-
longs contact time between fluoride and enamel centages of between 30-44%,16,17 but findings
in caries increment and improves fluoride uptake into the surface have been inconsistent and most comparisons
over 2 years. layers of enamel. have not found significant differences. Recent
Evidence available to studies have also found that varnish may slow
Caries prevention the progression of early enamel caries in the pri-
date suggests that For the permanent dentition, the anti-caries effect mary dentition.18,19 However, at present there is
fluoride varnish and of fluoride varnish has been confirmed in a num- insufficient evidence with which to assess caries
gel are equally ber of clinical trials. In a meta-analysis on the prevention effectiveness in primary teeth.
caries preventive effect of Duraphat varnish, eight No definite conclusions can yet be drawn
effective in caries studies were identified that were of high quality about the relative effectiveness of Duraphat and
prevention and provided Type 1 evidence.10,11 Based on these Fluor Protector varnishes.
studies, it was estimated the use of varnish result-
ed in a 38% reduction in caries increment (95% CI Clinical application
= 19–57%). In a second analysis, which included PATFs must be reapplied at regular intervals to
six additional studies, the estimated effect was be effective and the frequency will depend on
again a 38% reduction (95% CI = 25–50%). Stud- the risk level of the patient. Different application
ies involved subjects ranging in age from 6-to-15 frequencies have been effective in clinical trials,
years; the application frequency was most often but it is generally recommended that fluoride
biannual; and the majority of studies were varnish be applied at least every 6 months.
continued for at least 2 years. The application of varnish is straightforward
Recent findings are consistent with the con- and can be done by a dental hygienist or a
trained assistant (Table 2).20 The entire process
Table 2 Procedure for the application of fluoride varnish takes between 3–5 minutes per patient, depend-
ing upon the number of teeth present. Varnish is
• Remove excess moisture from teeth with a cotton swab, cotton roll, or air syringe. Meticulous drying generally well accepted by dental personnel and
of the teeth is not necessary because the varnish will set in presence of moisture.
patients, and has been found to be preferred to
• Dispense 0.5–1 ml of varnish in a dappen dish. This should be enough for the entire dentition.
fluoride gel by both groups.21 Dental hygienists
• Apply varnish as a thin layer using a disposable brush, or cotton pellet.
found varnish easier and faster to apply, and
• The entire tooth surface must be treated, but do not place large amounts on tooth surfaces. Avoid allowed for better control of moisture and fluo-
applying varnish to gingival tissues because of the risk of contact allergies.
ride ingestion.
• No drying is required after application because varnish sets in a few seconds.
No common or serious side effects of varnish
• The patient's mouth can be closed immediately following treatment. use have been reported. As a precaution, it is
• Patients can only have fluids or soft foods during the next four hours. Hard foods should be avoided. contraindicated in asthmatic patients due to
• Patients should not brush their teeth for the rest of the day. This enhances the uptake of fluoride into possible allergic reactions. The temporary tooth
the tooth structure.
discoloration caused by Duraphat varnish is
Note: Varnish is contraindicated for persons with a history of allergies or asthma. objectionable to some patients, but is readily
removed upon brushing.

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FLUORIDE GEL AND FOAM Table 3 Procedure for the application of fluoride gel
Fluoride gel applications are more commonly
used in the US and Canada. Gels are applied in • Mouth trays should be tried in the patient's mouth. It may be necessary to adapt or trim trays.
Styrofoam mouth trays, and the most widely • Patient should be seated upright and suction should be used during the procedure.
used gel is 1.23% F acidulated phosphate fluo- • Teeth should be air-dried before gel application. For caries prevention, cleaning or prophylaxis is
ride (APF). Fluoride foams are relatively unnecessary prior to PATF.
recent products that are similar to gels, but • Enough gel, or foam, should be used to completely cover the teeth, but should be no more than
2–2.5 grams per tray or 40% of the tray's volume.
have not been assessed in clinical trials.
• Upper and lower trays should be inserted separately.
Caries prevention • Fluoride should be applied for 4 minutes, not 1 minute.
The effectiveness of PATF gels has been docu- • Patient should expectorate for 1–2 minutes after tray removal.
mented in numerous clinical studies. In a meta- • Patient should not rinse, eat, or drink for at least 30 minutes after the procedure.
analysis of fluoride gel trials, van Rijkom et al. Note: For patients with porcelain or resin restorations, neutral sodium fluoride is recommended to
included nine studies (ten comparisons) of pro- prevent etching of restorations.
fessionally applied gels published between
1970 and 1992.7 The overall average prevented
fraction was 22% (95% CI = 18–25%) indicat- patients. However, some children find the
ing good evidence of effectiveness in perma- experience to be unpleasant, and gagging
nent teeth. All of the PATF studies used APF may occur with young children. The most
gel, application frequency varied from 1–2 common adverse effect is over-ingestion,
times per year, and the ages of subjects ranged which can lead to nausea and vomiting. The
from 6–15 years. inadvertent ingestion of gel can be prevented
No significant differences were found by the use of a suction device, seating the
between application frequencies, but this result patient upright, not overfilling trays, and
should be interpreted with caution because no using well-fitted trays.
head-to-head comparisons were included.
Although two randomized trials have found no IN-OFFICE FLUORIDE RINSES
difference between annual and biannual appli- Two-part fluoride rinses are being used more
cation frequencies,22,23 these studies could not frequently in North American practices instead
control for the number of additional PATF of gels or foams.28 These rinses consist of two
applications which may have been received fluorides, APF and stannous fluoride, which are
from private dentists not involved in the mixed or used concurrently; and are different
studies. Due to this possibility, there is a lack of from the mouthrinses used in school-based pro-
evidence that annual applications are effective grams or home-use.29
for caries prevention, and biannual applica- Two-part rinses are marketed as a preven-
tions are advisable. tive agent that is better tolerated than tray
A recently published Cochrane Review of flu- applications and reduces fluoride ingestion.
oride gels included 25 studies, 14 involving However, none of these claims has been sup-
PATF.24 Based on these studies, the DMFS pooled ported. First, it is unlikely these products are
prevented fraction was 28% (95% CI = 19–37%). as effective as other agents because the fluo-
The authors found insufficient information to ride concentrations are much lower compared
evaluate application frequency, or caries pre- with APF gel (1,500–3,000 ppm vs. 12,300
Studies of enamel
vention in the primary dentition. ppm). Caries prevention effectiveness has not fluoride uptake
Fluoride foams have not been assessed in been reported in any randomized clinical trials. suggest that a
clinical trials. Their characteristics are likely Second, the risk of ingestion is greater
four-minute
similar to gels because the same method of because rinses can be more easily swallowed.
application is used, their fluoride concentrations These rinses should never be used for young application is to be
are comparable, and fluoride enamel uptake is children because acute fluoride toxicity could recommended.
better.25 result if they were swallowed. Lastly, it is Reducing contact
doubtful whether in-office rinses are better
Clinical application tolerated by patients because of their sharp, time significantly
The frequency of gel application varies based on metallic taste. reduces enamel
the caries risk level of the patient, and is usually In-office fluoride rinses are not recommend- fluoride uptake
provided at least every 6 months. Gel applica- ed for caries prevention because other effective
tion is uncomplicated and can be performed by a ant-caries PATF products are readily available.
dental auxiliary (Table 3).
The four-minute application of fluoride gel is FLUORIDE INGESTION AND TOXICITY
recommended based on studies of enamel fluo- Fluoride applications must be carefully moni-
ride uptake.26,27 When contact time is reduced to tored because the potential for overingestion
one minute, enamel fluoride uptake is signifi- and toxicity does exist. Fluoride is rapidly
cantly less. No clinical data support the 1 minute absorbed in the gastrointestinal tract and young
application of any product when used in the typ- children are particularly vulnerable. Patients
ical 6-month recall system. Nevertheless, many should not be left unattended during the appli-
dental practices have reported applying fluoride cation of PATF.
gel for only 1 minute.28 A considerable amount of fluoride may be
Gel application is acceptable to most retained after gel application, even if suction

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PRACTICE

devices are used (on average 7.7 mg in the risk level of the patient, but should be pro-
children).30 The risk of fluoride ingestion with vided at least on a biannual basis when indi-
fluoride foam is reduced, compared with gel, cated (Type 1)
because a smaller amount is needed for applica- • For gel applications, gel should be retained in
tions. The exposure to and retention of fluoride the mouth for 4 minutes (Type 5)
foam by the patient may be significantly less • During topical fluoride application, precau-
compared with APF gel application.25 tions must be taken to minimize fluoride
Fluoride varnish has a high fluoride concen- ingestion (Type 5), and
tration, but its safety is acceptable. Varnish is • No cleaning or prophylaxis is necessary
fast setting, fluoride is slowly released, and a before the application of topical fluoride for
A cleaning or small amount is needed for the complete denti- caries prevention (Type 1)
prophylaxis is not tion. Measurements of fluoride after topical
necessary prior to the treatments with varnish show levels far below Table 4 provides a comparison of the differ-
those considered toxic.31,32 Consequently, var- ent types of PATFs considered in this review.
application of topical nishes may be a better alternative to fluoride Evidence indicates varnish and gel applications
fluorides gels, especially for young children.8 are similar in caries prevention effectiveness in
PATF is not a risk factor for dental fluorosis permanent teeth. Although no clinical trials
when used at 6-month intervals, and if precau- support the use of fluoride foam, it is likely to be
tions are taken to minimize ingestion.30 equivalent to fluoride gel use for caries preven-
tion. For several reasons, fluoride varnishes
IS A CLEANING NECESSARY PRIOR TO THE may be a better alternative to fluoride gels, par-
APPLICATION OF TOPICAL FLUORIDE? ticularly for young children. These reasons
Several clinical studies have reported that a include reduced risk of fluoride over-ingestion,
cleaning, or prophylaxis, is not necessary before greater patient acceptability, and faster and eas-
the application of topical fluorides.23,33,34 No ier application. The use of in-office two-part
significant differences in caries reduction were rinses is not recommended. When used appro-
found between patients who received a cleaning priately, professionally applied topical fluorides
before application of PATF and those patients are a safe, effective means of reducing caries
who did not receive a cleaning. risk among high-risk populations.

SUMMARY 1. Anderson R J. Changes in dental caries experience of 12-

year-old school children in two Somerset schools: a review
The following is a summary of the important sci- after an interval of 30 years. Br Dent J 1995;179:125-129.
entific facts and principles concerning the use of 2. Li S H, Kingman A, Forthofer R, Swango P. Comparison of
PATF: tooth surface-specific dental caries attack patterns in US
schoolchildren from two national surveys. J Dent Res 1993;
72:1398-1405.
• PATF should not be applied on a routine basis 3. Woodward G L, Lewis D W. The use of professionally applied
in dental practices. Fluoride applications are topical fluorides in the North York Public Dental Program.
only indicated for patients with decayed Quality Assurance Report No. 8, Community Dental Health
Services Research Unit, University of Toronto, 1995.
smooth surfaces and those at high caries risk 4. Olivier M, Brodeur J M, Simard P L. Efficacy of APF treatments
(Type 1) without prior toothcleaning targeted to high-risk children.
• Both APF gel and fluoride varnish are effec- Community Dent Oral Epidemiol 1992; 20: 38-42.
5. Bagramian R A. A 5-year school-based comprehensive
tive and can be recommended for caries pre- preventive program in Michigan, U.S.A. Community Dent Oral
vention in permanent teeth (Type 1) Epidemiol 1982; 10: 234-237.
• Frequency of PATF application will depend on 6. Bohannan H M, Klein S P, Disney J A, Bell R M, Graves R C,

Table 4 Comparison of professionally applied topical fluorides

Caries prevention Clinical application Fluoride ingestion Cost Acceptability

Varnish Effective in Easy Lowest risk Most Preferred by

high risk expensive patients and
children Application Moisture can be hygienists,
(permanent time varies better controlled compared with gel
teeth) than gel or foam
Gel Effective in Easy % retained can be Low cost Well-tolerated by
high risk substantial most patients, but
children Four-minute varnish is preferred
(permanent application Procedure must be
teeth) time followed to reduce
risk
Foam Not clinically Easy Risk of over- Low cost Not formally
tested ingestion is less assessed
Four-minute compared with gel
Likely similar application Likely to be similar
to gel time to gel
In-office Not clinically Most Greater risk of Least Not formally
two-part tested convenient swallowing expensive assessed
rinses Not recommended
for young children

316 BRITISH DENTAL JOURNAL VOLUME 195 NO. 6 SEPTEMBER 27 2003

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PRACTICE

Foch C B. A summary of the results of the National 21. Warren D P, Henson H A, Chan J T. Dental hygienist and
Preventive Dentistry Demonstration Program. J Can Dent patient comparisons of fluoride varnishes to fluoride gels.
Assoc 1985; 51: 435-441. J Dent Hyg 2000; 74: 94-101.
7. van Rijkom H M, Truin G J, van't Hof M A. A meta-analysis of 22. Horowitz H S, Doyle J. The effect of dental caries on topically
clinical studies on the caries-inhibiting effect of fluoride gel applied acidulated phosphate fluoride: results after three
treatment. Caries Res 1998; 32: 83-92. years. J Am Dent Assoc 1971; 82: 359-365.
8. Bawden J W. Fluoride varnish: a useful new tool for public 23. Johnston D W, Lewis D W. Three-year randomized trial of
health dentistry. J Public Health Dent 1998; 58: 266-269. professionally applied topical fluoride gel comparing annual
9. Beltran-Aguilar E D, Goldstein J W, Lockwood S A. Fluoride and biannual applications with/without prior prophylaxis.
varnishes: a review of their clinical use, cariostatic Caries Res 1995; 29: 331-336.
mechanism, efficacy and safety. J Am Dent Assoc 2000; 131: 24. Marinho V C C, Higgins J P T, Logan S, Sheiham A. Fluoride
589-596. gels for preventing dental caries in children and adolescents
10. Helfenstein U, Steiner M. Fluoride varnishes: a meta-analysis. (Cochrane Review). In: The Cochrane Library, Issue 2, 2002.
Community Dent Oral Epidemiol 1994; 22: 1-5. Oxford: Update Software.
11. Helfenstein U, Steiner M. A note concerning the caries 25. Whitford G M, Adair S M, McKnight C M, Perdue E C, Russell
preventive effect of Duraphat. Community Dent Oral C M. Enamel uptake and patient exposure to fluoride:
Epidemiol 1994; 22: 6-7. comparison of APF gel and foam. Pediatr Dent 1995; 7:
12. Zimmer S, Robke F J, Roulet J F. Caries prevention with 199-203.
fluoride varnish in a socially deprived community. 26. Wei S H Y, Hattab F N. Fluoride retention following topical
Community Dent Oral Epidemiol 1999; 27: 103-108. application of a new APF foam. Pediatr Dent 1989; 11:
13. Bravo M, Baca P, Llodra J C, Osorio E. A 24-month study 121-124.
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on different permanent first molar surfaces. J Public Health fluoride acquisition from APF gels. II. In vivo study. Pediatr
Dent 1997; 57: 184-186. Dent 1988; 10: 173-177.
14. Bravo M, Garcia-Anllo I, Baca P, Llodra J C. A 48-month 28. Warren D P, Hensen H A, Chan J T. A survey of in-office use of
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16. Holm A K. Effect of fluoride varnish (Duraphat) in preschool 31. Ekstrand J, Koch G, Petersson L G. Plasma fluoride
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