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

18

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

28

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!

30

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