By DIANNE GLASSCOE WATTERSON, RDH, BS, MBA
Dear Dianne,
My boss went to a meeting and heard a speaker say that we should apply topical fluoride to all patients. Now he wants me to push fluoride and recommend it to all my patients. Of course, having been a dental hygienist for 20 years, I know the benefits of fluoride. But I have patients who come in every six months who have not had cavities or other dental problems for many years. I can’t really see how fluoride would be helpful for these patients.
Honestly, I think the extra production is the driving factor for him. Since I’m not convinced that every patient needs fluoride, what should I say when patients ask why they need it? Is fluoride really useful for every patient?
-Sceptical RDH
Dear Skeptic,
Profit is not “bad” since every business must be profitable to survive. But when a company advertises a product as a “profit center,” it can seem unethical. When presented with the math—that X treatments equals Y dollars for the practice—the buyer must figure out how to integrate the treatment into the current protocol. It may be a good treatment, but whether patients actually benefit from the treatment is sometimes not even considered if profit is the main motive.
I think we have to be careful about how we justify certain treatments or supplements. Is the decision based on a speaker’s zealous presentation, a profit motive, or evidence-based science? The proper motivation would be for the treatment, whatever it is, to be supported by unbiased scientific evidence that clearly demonstrates its effectiveness and benefit to the patient.
To guide the decision-making process, the American Dental Association (ADA) published a document, “Professionally Applied Topical Fluoride: An Executive Summary of Evidence-Based Clinical Recommendations,” in 2006. To my knowledge, there are no new discoveries on topical fluoride has been offered since then, so the information is still relevant. A panel of expert dental professionals “assessed the collective body of scientific evidence on the effectiveness of professionally applied topical fluoride in the prevention of dental caries.” Here is a summary of the panel’s findings, based on the evidence:
- Fluoride gel is effective in preventing tooth decay in school-aged children.
- Patients whose caries risk is low, as defined in the document, may not receive additional benefit from professional topical fluoride application.
- There is substantial caries reduction data for professionally applied topical fluoride treatments of four minutes or longer. In contrast, there is laboratory data on the effectiveness of one-minute fluoride gel applications (but no clinical equivalence).
- Fluoride varnish applied every six months is effective in preventing caries in the primary and permanent dentition of children and adolescents.
- Two or more applications of fluoride varnish per year are effective in preventing caries in high-risk populations.
- Fluoride varnish applications take less time, create less patient discomfort, and achieve greater patient acceptance than fluoride gel, especially in preschool children.
- Four-minute applications of fluoride foam every six months are effective in preventing caries in the primary dentition and recently erupted permanent first molars.
- There is insufficient evidence to consider whether there is a difference in the effectiveness of sodium fluoride versus acidified fluorophosphate gels.
From the evidence reviewed by the committee, it was found that people over the age of six at low risk of caries would probably not benefit from topical fluoride supplements. Low risk is defined as “No incipient or cavitated primary or secondary carious lesions in the past three years and no factors that may increase the risk of caries”.
The panel defined moderate risk as “One or two incipient or cavitated primary or secondary caries lesions in the past three years. No incipient or cavitated primary or secondary caries lesions in the past three years, but the presence of at least one factor that may increase the risk caries.”
High risk was defined as “Three or more incipient or cavitated primary or secondary carious lesions in the past three years. Presence of multiple factors that may increase caries risk. Suboptimal fluoride exposure. Dry mouth.”
All three classifications list risk factors that must be evaluated. What are these risks that increase a person’s tendency to develop tooth decay? The panel listed these risk factors:
“Factors that increase the risk of developing caries may also include, but are not limited to, high titers of cariogenic bacteria, poor oral hygiene, prolonged breastfeeding (bottle or breast), poor family dental health, developmental or acquired enamel defects, genetic abnormality of teeth. , multiple surface restorations, chemotherapy or radiation therapy, eating disorders, drug or alcohol abuse, irregular dental care, carious diet, active orthodontic treatment, presence of exposed root surfaces, restoration protrusions and open margins, and physical or mental disability with inability or unavailability with based on findings from population studies, groups with low socioeconomic status have been found to have an increased risk of caries. In children too young to base risk on caries history, low socioeconomic status should be considered as a caries risk factor, drug-, radiation-, or disease-induced dry mouth.”
Every practice has patients who fall into the moderate to high risk category. According to science, these and only these patients will benefit from topically applied fluoride. Patients at low caries risk should not be given fluoride supplements, as the benefit is negligible.
When patients are at moderate to high risk, you should be able to tell the patient why fluoride would be beneficial based on the risk factors. If the risk is low, fluoride should not be offered.
Topical applications of fluoride to treat hypersensitivity are useful in some patients, especially when large calculus deposits are removed from exposed root surfaces. However, the panel did not discuss fluoride for the treatment of sensitivity.
Another consideration about fluoride varnish is that patients leave with a rough, unpleasant film on their teeth after application. The vast majority of patients enjoy that nice, clean, smooth feeling after visiting their hygienist. Hygienists have reported that patients complain about the unpleasant sensation of fluoride varnish. I don’t think we benefit when patients leave the practice unhappy.
The bottom line in deciding whether topical fluoride is a beneficial supplement is to consider the patient’s risk factors. Clearly, blanket fluoride mandates for everyone are not appropriate.
The best,
DIANE RDH
DIANNE GLASSCOE WATTERSON, RDH, BS, MBA, is an award-winning speaker, author and consultant. He has published hundreds of articles, several textbook chapters, an instructional video on instrument sharpening, and two books. For information about upcoming talks or products, visit her website atwww.professionaldentalmgmt.com. Dianne can be reached at (336)472-3515 or by email [email protected].
