Making the case for fluoride varnishes

June 7, 2010 | modernhygienist.com

Photo: Getty Images/Altrendo Images

If I asked you to pick the most important preventive dental product to date, what would you choose?  Most of you would say fluoride…right? Fluoride has been dentistry’s greatest success in preventing dental caries.The profession, patients and even insurance companies have accepted fluoride. You can find it in numerous products from water to toothpaste, and it is an integral part of our routine preventive care-both in the dental office and at home.

But what would you say if I asked you to pick the most important advancement in fluoride in recent years? I hope you didn’t say “minute gels” because there is no clinical research to support 1-minute applications. And I hope you didn’t say dual-rinse products because they don’t even contain American Dental Association approved concentrations of APF and Stannous. If you said varnish, you are correct!  If you said, “what is fluoride varnish?” this article is written for you.

A little history
Professional fluoride treatments have changed over the last 40 years.  Stannous fluoride, a liquid mixed fresh daily and painted on the teeth with cotton swabs, was the original office formulation. It tasted metallic and was messy to apply. Fluoride gels applied in trays came next, then fluoride foams that were so much more convenient and palatable. Fluoride varnish is the most recent fluoride introduced in the U.S.

Fluoride varnish was introduced in1964 under the trade name Duraphat® (Colgate Pharmaceuticals, Canton MA 02021) and was the standard of practice for the professional application of topical fluoride in Western Europe, Scandinavia and Canada for more than 25 years.  In 1994, the Federal Food and Drug Administration (FDA) granted approval of fluoride varnish in the United States for use as a cavity liner and desensitizing agent.

A colophonium resin that came in a tube was the first generation of fluoride varnish. The amber colored varnish still is available and still is an excellent choice for mass applications in clinics and public health settings. Patients do not like the temporary yellow color, but applying the varnish to all surfaces of the teeth, except for the facials of the “smile line,” is an easy remedy.

A white or tooth-colored resin represents the second generation of varnish. It is unit dispensed for convenience, although it is a little less economical. Patients may complain somewhat that it leaves their teeth feeling “waxy,” but once you explain the benefits, they usually are more accepting.  Both types of varnish contain 5% sodium fluoride in suspension.

Caries management
Many dentists began using fluoride varnish “off -label” as a caries preventive agent in place of fluoride gels and foams that required a 4-minute application. In 2006, the American Dental Association Council on Scientific Affairs formed an expert panel of scientists to evaluate the scientific evidence on the effectiveness of professional fluorides for caries prevention.The panel’s recommendations, which were published in the Journal of the American Dental Association that same year, supported the use of fluoride varnish for patients at moderate- and high-risk for dental caries.

The ADA expert panel “encouraged dentists to employ caries risk assessment strategies in their practices.” The panel offered a classification system for identifying low- to high-risk patients with suggested frequencies for fluoride type and application. The following is what they recommended for applying fluoride varnishes:

• · Professional application of fluoride was not recommended for low caries risk patients because they “may not receive additional benefits from professional fluoride application.”

• · Moderate risk patients should receive varnish applications at 6-month intervals and high-risk patients at either 6-month or 3-month intervals.

Caries management and children
Because it is easy to use and safe for children, infants and toddlers, fluoride varnish was the only fluoride the ADA expert panel recommended for children 6 and younger at moderate or high risk for caries, at 3- or 6-month intervals respectively. The ADA, as well as the American Association of Pediatric Dentistry, does not recommend using fluoride gels/foams in trays or fluoride rinses for children 6 and younger because of the toxicity risk if swallowed. These recommendations hold true for children who may be uncooperative or those with special needs.

Caries management and the older patient
On the opposite side of the patient age spectrum, the U.S. population is aging with adults older than 65 increasing the most rapidly proportionally. Medications resulting in xerostomia, decreasing dexterity for self-care, systemic conditions and institutionalization will result in a large number of these adults falling into the moderate- and high-risk category for dental caries. Studies report that at least 50% of adults older than 50 experience root caries. Fluoride varnish is an excellent therapy for elderly patients or periodontal patients who have clinical attachment loss, exposing root surfaces to caries risk.

In institutionalized elderly, tray treatments are difficult to apply unless suction is available. Even with suction, tray treatments are not an option with an intubated or unconscious patient.

Don’t ignore risk factors
While fluoride varnish may sound like the answer to caries management, risk factors such as high bacterial counts, low dietary calcium, acidity from foods or GERD, cariogenic diet and xerostomia, need to be addressed. A combination of fluoride varnish with antimicrobial agents, xylitol, amorphous calcium phosphate along with biofilm control can be individualized for each patient at any time.  Caries risk can and will change over time because of different events occurring in an individual’s life.  Risk assessment must be performed at each recare visit along with modifications in the recommended preventive interventions or therapies.

Fluoride varnish application technique
Most clinical studies recommend a toothbrush prophy be performed to remove excess biofilm and plaque. Because varnish sets when it comes in contact with moisture (contributing to its low risk of toxicity), teeth should be dried with gauze or air so the maximum amount of varnish adheres to the tooth surface. These studies also report that having the patient refrain from brushing and eating crunchy foods for 12 hours results in the varnish remaining in contact with the teeth for that amount of time. Note these instructions are based on published clinical studies and may vary from some manufacturers’ instructions. As with any dental procedure, choosing evidence-based practices offers the most effective outcomes and benefits for our patients.

Fluoride varnish and hypersensitivity
Varnishes are ADA approved for dental hypersensitivity that results when fluids in open dentinal tubules create pressure on nerves, causing pain. Fluoride varnish (any fluoride for that matter) forms a layer of calcium fluoride that blocks the tubules and prevents this fluid flow.  Varnishes have the advantage over gels, foams, rinses and pastes because of their ability to retain on the tooth surface for hours. Varnishes are an excellent therapy for patients who have attachment loss or who experience sensitivity from whitening or other dental products. Some patients who are sensitive during and after scaling and root planing procedures respond very well with reduction in hypersensitivity.

So what are you waiting for?  
Fluoride varnishes offer a safe, easy, evidence-based treatment to prevent dental caries and hypersensitivity for patients from infancy to geriatrics. Start tomorrow with that moderate- to high-risk patient who dislikes the tray in her mouth for 4 minutes or that uncooperative child with a history of caries. Soon you will join those of us who wouldn’t use any other method of fluoride.

Donna Warren Morris, RDH, Med is an Associate Professor at the University of Texas Dental Branch-Houston. 

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