Fluoride Update
Hugh Silk, MD, MPH
Clinical Associate Professor
May 13, 2012
Family Medicine and Community Health
Learning Objectives
By the end of this talk participants will be able to discuss:
• Benefits of fluoride
• Updates in
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fluoridated water levels
fluoride prescribing
Bottled water and fluoride
mixing formula with fluoridated water
• The benefits and process for providing fluoride
varnish in your office
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Acknowledgment: Some materials
today are used from Smiles for Life
8 annotated 50 minute PowerPoint modules
www.smilesforlifeoralhealth.org
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Disclosures
• I have no relevant financial relationships with the
manufacturer(s) of any commercial product(s)
and/or provider(s) of commercial services
discussed in this CME activity
• I will be speaking about fluoride varnish as an
off-label use product for caries prevention; it has
been approved by US Food and Drug Admin as
a cavity liner and treatment of sensitive teeth
only; I will present evidence on proven benefit of
product
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A Reminder of the
Benefits of Fluoride
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Effects and Sources of Fluoride
Topical Mechanisms (main effect)
• Inhibiting tooth demineralization
• Enhancing remineralization
• Inhibiting bacterial metabolism
Systemic Mechanisms
• Reducing enamel solubility through incorporation
into the tooth during development
Fluoride Sources
• Topical:
• Dietary:
Fluoride toothpastes
Gels, foams, mouthwashes
Fluoride varnish
Water fluoridation
Dietary fluoride supplements
Photos: Joanna Douglass, BDS, DDS
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Evidence of Benefit
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General Population (USPSTF 1989, 1996)
• Fluoridated toothpaste (I, A)
High Risk Populations (MMWR 2001)
• Fluoride varnishes on permanent teeth (I, A)
• Fluoride varnish on high risk infants (I, A)
• Fluoride supplements if water <0.3ppm (6-12 year olds) (I, A)
Cochrane Data Base (2006)
• Fluoride varnishes on primary and permanent teeth (I,A)
I: Indicates a recommendation is based on evidence from
properly constructed randomized controlled trials
A: Indicates a high certainty that net benefit is substantial
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Fluoride Use Recommendations
All children should receive fluoride through water
fluoridation or fluoride supplements.
No
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Fluorosis
Appearance and Significance
• White mottling of teeth due to chronic
excessive exposure to fluoride during tooth
development
• Cosmetic issue
Risk Reduction
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Moderate Fluorosis
Photo: Joanna Douglass, BDS, DDS
• Determine fluoride content of drinking
water before prescribing F
Severe Fluorosis
• Use current dosage schedules
• Avoid duplicating fluoride prescriptions
(e.g. 2,500 Head start children in MA take
fluoride supplements daily)
• Use only a smear of toothpaste
Photo: John O'Donnell, DDS
• Fluoride varnish does not cause fluorosis
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Updates in:
• fluoridated water levels
• fluoride prescribing
• Bottled water and fluoride
• mixing formula with fluoridated
water
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Water fluoridation
• CDC: 1 of top 10 public health achievements of
the 20th century
• Fluoride in water: colorless, odorless, tasteless
• Fluoridation is cost effective: $1 spent saves $38
Communities with fluoridated water have less
cavities (J Pub Health Dent 2010;70:227-33)
• Removing F -> median increase of 18% caries (Am
J Prev Med 2002;23(suppl:21-54))
• 65% of MA is receiving benefits of water
fluoridation
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Fluoridation levels
• Department of Health and Human
Services proposed setting its
recommended level at 0.7 mg/L for
benefits against tooth decay
• Environmental Protection Agency 4 mg/L
to avoid risks (fluorosis)
• MA recommended fluoridation level: 0.91.2 ppm
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http://www.mass.gov/eohhs/docs/dph/c
om-health/fluoride-census.pdf
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Bottled Water
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29 gallons per person annually
Cultural variabilities: latino ↑ water=illness
FDA does not require F level on bottle
5% list level; 80% have suboptimal level
Different batches have different levels!
Deionized, distilled, purified – no F (unless indicated)
No studies comparing bottle water drinkers
to consistent fluoridated water users
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Formula and Fluoridated Water
• 61% of infants have received some
formula by age 6 months (CDC)
• Vast majority use powdered source;
majority mix it with tap water
• ADA based on Iowa Fluoride Study states
that use of fluoridated water to mix powder
formula may lead to mild fluorosis (dose
dependent) – JADA 2011;142:79-87
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Therefore
• OK to use fluoridated water to reconstitute
powder formula but be aware of small risk
for mild fluorosis (1.03 ppm)
• Note – mild fluorosis is hard to see
• If a concern – can use ready-to-feed
formula (0.15 ppm), reconstituted liquid
formula (0.64 ppm) OR mix powder with
non-fluoridated water
• Consider – mix some with fluoridated
water and some without
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How Much Toothpaste?
Guidelines
• Most preschool children swallow much of the toothpaste placed on the
brush. These guidelines take this into account and these amounts are
safe to swallow, but spitting out should always be encouraged
• Parents should keep toothpaste tubes out of reach of small children
Less than 2 years: small smear
2 years & over : pea sized
Photos: Joanna Douglass, BDS, DDS
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Fluoridation Supplementation
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Fluoride Supplementation
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Guidelines
• Prescribe dietary fluoride supplements to children with high caries risk
who lack access to optimally fluoridated water (ADA 2010)
• Determine your patient's source of water and its fluoride content
• Test well water before prescribing systemic fluoride
chewable
liquid
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Medical Providers and
Fluoride Varnish
A gateway to more oral health and
how we are making it work
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Building Upon the Work
Done by Others
• The Gurus
– North Carolina
– Washington
– Maryland
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Our Comprehensive program
• Preparation - Project Coordinator prior to site training to allow our
trainer to enter a practice ready to implement change
• Commitment – ensure the office starts varnish use “same day”
• Practice work flow – identify eligible patients; work it into visits
• Clinical record – incorporate oral health prompts into the record
• Billing –Add codes to encounter forms or EHR billing system
• Train ALL staff – establish buy-in; use web-based training for those
who are absent
• Hands on practice - hands-on patient experiences with hygienist
• Supply provisions - comprehensive informational packet, patient
posters, laminated fact cards, carrying cases with 50 free varnish
packets, patient handouts, gauze, gloves, billing stickers/information
• Follow-up – “adopt a practice”
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Fluoride Varnish Benefits
• Safe, effective, inexpensive
• Quickly and easily applied
• Can eat and drink immediately
after
• Studies demonstrate 38%
reduction in caries with use
• Can reverse early decay (white
spots) and slows enamel
destruction in ECC
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Application
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Steps
1.Use gauze to dry the teeth as much as
possible. Varnish will not adhere if teeth
are wet
2. Apply varnish to dried teeth, starting in
posterior
3. Apply varnish to anterior teeth last
Photo: ICOHP
4.Saliva contamination after application is
fine as varnish sets in contact with saliva
Photo: Joanna Douglass, BDS, DDS
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The Benefits of Promoting Oral Health
in Your Practice
• Patient Benefits:
– Fluoride varnish use reduces caries by 38%
– Children in practices using fluoride varnish are more
likely to establish dental homes
• Office Benefits:
– Adopting current best practices (42 states)
– Increased office revenue ($26 per pt)
• Low volume (5 pts per week) - $6,396 net revenue
• High volume (5 pts per day) - $31,980 net revenue
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Massachusetts
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Third Edition
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Conclusions
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Oral disease is prevalent
Fluoride is proven to reduce disease
Fluoridated water is easiest for exposure
Explain formula mixing issue
Supplements for all risk children
Counsel about toothpaste to avoid fluorosis
You can do Fluoride Varnish, and you
should! Sign up now.
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Questions
www.smilesforlifeoralhealth.org
hugh.silk@umassmemorial.org
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