The American Dental Association’s New Fluoride Guidelines

If a little fluoride is able to prevent tooth decay, then more fluoride will prevent more tooth decay, right? That is the theory behind professional fluoride applications. It really works, too. People who get more professional fluoride treatments have less tooth decay. Ask our friends at MassHealth. The people who administer the Massachusetts version of Medicaid offer to pay dentists to apply fluoride to children’s teeth far more frequently than the two times a year that most dental insurance companies offer. However, does anyone get enough fluoride just from their drinking water and toothpaste? According to the American Dental Association, some people do.

The August 2006 issue of The Journal of the American Dental Association (JADA) contains the report of a meta study (a paper that reports and analyzes the results of several clinical studies) of the effectiveness of professional fluoride applications. JADA provides dentists a clear authority in matters of dental practice, procedures and treatments. JADA throws the full weight of its editorial conviction behind this paper and its recommendations.

The paper, “Professionally applied topical fluoride, Evidence-based clinical recommendations,” is a product of the ADA Council on Scientific Affairs (CSA). Per its mission statement, the CSA “..serves the public and the profession as the primary resource on the science of dentistry.” How will the recommendations of this committee effect dental practices and your dental health?

Fluoride protects teeth from decay by joining with minerals in the outer layer of the tooth. Fluoridated teeth are more resistant to the acid that decay causing bacteria produce. The effectiveness of fluoride depends on how long the fluoride treatment is in contact with teeth, the chemistry of the fluoride treatment, and patient compliance. Compliance or patient acceptance is very important for fluoride treatments. For example, even though drinking water has a very low concentration of fluoride, high compliance makes fluoridated water a very effective decay preventing technique. Children drink fluoridated water regularly, they do not taste anything, parents do not need to remember to give water to their children, the water may even be flavored.

Fluoride is available in many forms. There is sodium fluoride (NaF), monofluorophosphate (MFP), and stannous fluoride (SnF). There are fluoride rinses, gels, foams, tablets and varnishes. Home treatments include over the counter and prescription rinses, toothpastes, gels, and tablets. Remember that while fluoridated drinking water is safe for young children, children who may swallow fluoride toothpastes and rinses should not use those preparations. The difference is that toothpaste and rinses have a much higher concentration of fluoride.

Dentists and dental hygienists provide fluoride treatments using rinses, foams, gels, and varnishes. Relying on information from continuing education courses, journal articles, advertisements and visits from company representatives, each dental office may have their own fluoride treatment regimen. The ADA provides guidelines to dentists to try to standardize and rationalize treatments based on the results of scientific studies.

The big news in the CSA’s paper is their assertion that professional fluoride applications are not necessary for every person. Their recommendation for people with a low risk of tooth decay is that the fluoride in drinking water and toothpaste is enough. The CSA believes that additional fluoride as in professional applications does not decrease their risk of decay further.

The CSA classifies patients who have no tooth decay for at least three years and no other risk factors as low risk patients. The CSA advises that low risk patients do not benefit from professional fluoride applications. In other words, people who do not get tooth decay will not get less tooth decay if their dentist or hygienist gives them a fluoride application.

Factors that increase the risk of decay include poor oral hygiene, a high level of infection with decay causing bacteria, prolonged nursing (bottle or breast), poor family dental health, defects in dental enamel, many large restorations (fillings), xerostomia (dry mouth) caused by disease, medication or radiation treatment, eating disorders, drug or alcohol abuse, irregular dental care, a diet high in acid or sugar, braces, gum loss or exposed tooth roots, and a physical or mental inability to brush and floss correctly. The CSA points out that poverty increases the risk of tooth decay.

Moderate risk patients have little or no decay in the previous few years, but do have some of the factors that increase their risk. Moderate risk patients benefit from the application of fluoride gel or varnish every 6 months.

Young children (under 6) with any history of decay and older patients with at least a few cavities and multiple risk factors, are at high risk for decay. High risk patients benefit from professional fluoride applications two or more times per year depending on the patient and the dentist’s preference.

Will the average dentist follow these recommendations? A brief discussion with a few colleagues uncovers a few reasons why dentists will continue to provide fluoride applications to all of their young patients. Parents expect their children to receive a fluoride treatment. For many dentists, it is easier to continue to provide this service than to explain repeatedly a change in routine. A change in the patient’s risk factors could occur. For example, a child could begin drinking carbonated beverages; if so, the professionally applied fluoride may give that patient some protection. Skipping office fluoride treatments may cause dissatisfaction if the patient ever did have tooth decay.

One colleague, Dr. Carole Palmer, is Professor and Head of the Division of Nutrition and Oral Health Promotion at Tufts University School of Dental Medicine. Dr. Palmer presents a different view. She supports the recommendations of the panel. She believes that dentists should recognize that many factors effect a patient’s caries risk. Dentists should adjust fluoride treatments accordingly.

Speak with your dentist or hygienist about this interesting issue. Work with them to develop a plan for your children’s and your own fluoride use.

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