ByJoAnn R. Gurenlian, RDH, PhD
The American Dental Association (ADA) has a policy to update clinical recommendations and evidence every five years. Most recently, they published their report on professionally applied topical fluorides and prescription strength home-use topical fluorides to prevent caries.1 Since some of you have requested information on fluorides, this column will be devoted to summarizing the panel recommendations from the ADA Council on Scientific Affairs (CSA).
As part of the process of conducting the review of fluoride for caries prevention, the panel evaluated sodium, stannous, and acidulated phosphate fluoride (APF). Varnishes, gels, foams, mouth rinses, and prophylaxis pastes were considered. Seventy-one trials from 82 articles were reviewed to assess the efficacy of various fluoride agents for preventing caries.
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The strength of the recommendations were made using a grading system adapted from the U.S. Preventive Services Task Force system and included the following recommendations: strong, in favor, weak, expert opinion for, expert opinion against, and against.
Another element considered was the net benefit rating, taking into consideration whether the benefit outweighs potential harm, the benefit is balanced with potential harm, there is no benefit, or the potential harm outweighs the benefit.
Key recommendations from the CSA panel include:
• Topical fluoride agents are recommended only for people that are at elevated risk of developing caries.
• For patients 6 years or older who are at risk, use2.26% fluoride varnish
- 1.23% fluoride (APF) gel
- Prescription strength, home-use 0.05% fluoride gel or paste
- 0.09% fluoride mouth rinse
• Only 2.26% fluoride varnish is recommended for children younger than 6 years of age.
The strengths of these recommendations varied from "in favor" to "expert opinion for."
Of interest, the panel found evidence of no benefit from using 0.1% fluoride varnish in children, and no benefit for performing prophylaxis before applying 1.23% APF gel in both the primary and permanent dentitions of children. Further, there was no benefit found for using prophylaxis pastes containing fluoride on the primary or permanent teeth of children.
The panel noted that these recommendations are not meant to represent a standard of care. Rather, they are provided to summarize current evidence and to assist practitioners in evaluating caries risk, patient needs and preferences, and professional judgment.
Further, the panel advocated that in developing a caries prevention plan that includes use of fluoride; the practitioner and patient must balance potential benefits with potential harm. Topical fluoride potential harm includes nausea, vomiting, and dental fluorosis. The panel noted that there is lower potential harm with fluoride varnish dispensed in unit doses. The amount of fluoride placed via fluoride varnish is one-tenth that of other professionally applied fluoride products.2
As with most reviews of this nature, the panel found areas requiring further research using well-designed clinical trials. For example, the panel noted that research is needed for particular subgroups, including adults aged 18 through 65, high-risk adults older than 65, and populations with chronic diseases. Studies are needed to examine strategies for managing xerostomia-induced coronal and root caries. The economic benefit of topical fluoride in various caries risk populations needs to be studied.
Lastly, the panel supports research concerning the best ways to help oral-health professionals use clinical recommendations in practice.
Having an opportunity to review evidence-based clinical recommendations on topical fluoride agents helps us understand several key points. First, research is dynamic and findings change often. Remaining current on best practices is assisted by expert panels that conduct systematic reviews and meta-analyses. Second, even with this information, there are limits based on the designs of the studies conducted. Therefore, we need to be mindful to maintain a context for the findings.
Clinical recommendations are one part of the process for making evidence-based decisions. These recommendations support our critical thinking process and assist us in helping our patients understand our rationale for prevention and treatment interventions. For more information about clinical recommendations for the use of topical fluoride agents for caries prevention, visit http://jada.ada.org.
1. Weyant RJ, Tracy SL, Anselmo T, et al. Topical fluoride for caries prevention: Executive summary of the updated clinical recommendations and supporting systematic review. JADA 2013;144(11):1279-1291.
2. Beltran-Aguilar ED, Goldstein JW, Lockwood SA. Fluoride varnishes: a review of their clinical use, cariostatic mechanism, efficacy and safety. JADA 2000;131(5):589-596.
JOANN R. GURENLIAN, RDH, PhD, is president of Gurenlian & Associates, and provides consulting services and continuing-education programs to health-care providers. She is a professor and dental hygiene graduate program director at Idaho State University, and president of the International Federation of Dental Hygienists.