Missouri Academy of
General Dentistry

Early Intervention

Fluoride Varnish: Reversing the Caries Process
By Craig S. Hollander DDS, MS Diplomate, American Board of Pediatric Dentistry

The headline from a recent CDC report reads "Oral Health Improv­ing for Most Americans, But Tooth Decay Among Preschool Children on the Rise." 1 The article states that although Americans of all ages continue to experience improve­ments in their oral health, tooth decay in primary teeth of children aged 2-5 increased from 24 percent to 28 percent between 1988-1994 and 1999-2004. This contrasts with other age groups where there was a decrease in tooth decay in perma­nent teeth for children, teens and adults. The report also indicates that tooth decay disproportionately affects poor children. Three times as many children aged 6-11 (12%) from families with incomes below the federal poverty line had un­treated decay compared with chil­dren from families with incomes above the poverty line.
In order for the current trend of caries in young children to decrease, early intervention is crucial. Chil­dren will need to be seen earlier than the conventional age three visit, because the caries process has already started on many of them.

Fluoride varnish (FV) was in­troduced in 1964 and has been used successfully in Europe since the 1980's. FDA approval for the prod­uct in the U.S. occurred in 1994 for use as a desensitizing agent for teeth that hurt when eating cold or sweet foods. Studies of different fluorides have shown FV to reduce caries due to incidence from 18-70% but the quality of the study designs varies greatly and do not allow good com­parisons between products.2 Cur­rently, the use of FV for caries re­duction is an off-label use, although like many therapies not approved for use in children, it provides ben­efit for them.

Fluoride varnish is a concen­trated topical fluoride with a resin or synthetic base that allows it to stick to teeth. The 5% concentra­tion of the sodium fluoride is 5 times the amount that is available in over-the-counter toothpaste. The var­nish is easily applied to the dried teeth of a child using a small paint brush or applicator, and the var­nish adheres to the teeth when in contact with saliva. The only side effect is a temporary yellow-brown discoloration which will wear off when the teeth are brushed, and there are new white varnishes now available as well. Parents are ad­vised that they should not brush their child's teeth until the next day to maximize the caries protec­tive effect, and that the yellow dis­coloration will come off at that time. FV can be applied on kids of any age, and will especially benefit in­fants at high risk for developing dental caries, before their teeth de­velop decalcifications.

A crying, uncooperative child is going to make application of the varnish even easier, because the mouth will be wide open. A health care provider can place varnish on all primary tooth surfaces in less than a minute, and the effects of the varnish will last several months. Children at high risk for dental caries are encouraged to have FV placed every 90 days, and for children at low or moderate risk for developing dental decay can have the FV placed every 6 months.

Fluoride varnish is extremely cost effective, costing as little as $1.25 per application for less than 5 minutes of working time. Furthermore, it is less likely to be swallowed as other topical fluorides are prone to be, thus reducing the risk of nausea or fluorosis of perma­nent teeth from excess ingestion of the fluoride ion.

General dentists have the unique ad­vantage of talking about caries preven­tion for infants while they are treating the pregnant mother. Once the child is born, a brief lap exam scheduled around the child's first birthday will initiate the lifetime habit of regular dental checkups. The general dentist would be able to identify decalcifications (Figure 1 A.), and apply fluoride varnish before the lesion cavitates (Figure IB.)

The Missouri Academy of Pediatric Dentistry is following in the footsteps of North Carolina, Washing­ton State, Ohio, Michigan, California, and other dental societies by creating a workshop to train health care providers how to perform an infant oral health exami­nation, assess caries risk, and apply fluoride varnish. This Screening and Varnish for Everyone (S.A.V.E.) workshop can provide the information you need to implement an infant oral health program for your dental office. Health care providers who take the S.A.V.E. workshop are eligible to purchase fluoride varnish at a discounted rate from participating manu­facturers. Be on the lookout for the S.A.V.E. workshop which will be presented at the 2008 MDA Mid-Winter meeting. Together, we can create a decline in the incidence of dental caries for young children.

There is a relatively new toothpaste on the market that is geared towards those individuals who get canker sores due to sodium lauryl sulphate (SLS) sensitivity. As you may know, SLS is a chemical agent that is found in such products as toothpaste, hair shampoo, bubble bath, and carpet cleaners, products which consumers expect to "foam up". SLS can dissolve skin oils, and create an irritation in some people which can exacer­bate itself as an exzema on the skin, or canker sores in the mouth.

Tanner Tasty Paste (www.tannertastypaste.com) was started by a pediatric dentist who was trying to lose weight by creating a toothpaste that came in chocolate or vanilla flavors. Her thought was that if mouth tasted like she just ate ice cream, she'd be less inclined to snack on desserts. The toothpastes were developed without the preservative SLS, so individuals who get frequent canker sores may be helped by using this toothpaste. It is also helpful for those picky kids who are unable to find a toothpaste flavor they like. It's rare to find a young child who doesn't like chocolate or vanilla. Visit the website to order some sample sachets, or to have a supply of toothpaste sent to your office.

Footnotes
1. Trends in oral health status: United States, 1988-1994 and 1999-2004. Series 11, Number 248. 104 pp. (PHS) 2007-1698
2. Adair, SM: Evidence-baseduse of fluo­ride in contemporary pediatric dental prac­tice. Fed Dent 28(2), 133-142, 2006
Other Resources
The ADA Council on Scientific Affairs:
Professionally Applied topical fluoride: Evi­dence-based clinical recommendation. JADA 137 pp.1151-1159, Aug 2006.
AWeintraubJA, Ramos-Gomez F, et. al:
Fluoride varnish efficacy in preventing child­hood caries. J Dent Res 85(2) 172-176, 2006

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